PACIO Personal Functioning and Engagement Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-narrative-history-of-status | Version: 2.0.0-ballot | |||
Active as of 2024-08-13 | Computable Name: PFENarrativeHistoryOfStatus |
An exchange of a narrative summary regarding the most recent prior status immediately preceding the current admission, illness, or exacerbation for a patient. The use of this profile is encouraged in the absence of formal prior level assessments. For formal assessments conducted with for example, an assessment instrument, use the collection and single observation profiles defined in this IG to capture assessment data.
Example Usage Scenarios:
The following are example usage scenarios for this Profile:
The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.
Each Personal Functioning and Engagement Narrative History of Status must have:
Each Personal Functioning and Engagement Narrative History of Status must support:
* see guidance below
Profile specific implementation guidance:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location |
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) |
status | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. | |
category | 1..* | CodeableConcept | (USCDI) Service category | |
Slices for category | Content/Rules for all slices | |||
category:us-core | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) | |
Slices for category | Content/Rules for all slices | |||
category:PFEDomain | S | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) |
code | 1..1 | CodeableConcept | US Core Report Code | |
effective[x] | 1..1 | dateTime, Period | Diagnostically relevant time (typically the time of the procedure) | |
performer | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. | |
presentedForm | 1..* | Attachment | The narrative text describing the patient's history of status. | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location |
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) |
category:PFEDomain | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Health care event when test ordered |
effective[x] | SΣC | 1..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
performer | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) | (USCDI) Observations |
media | SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
presentedForm | S | 1..* | Attachment | The narrative text describing the patient's history of status. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG | |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location | ||||
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
category:PFEDomain | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) | ||||
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Health care event when test ordered | ||||
effective[x] | SΣC | 1..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made | ||||
performer | SΣ | 1..* | Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
presentedForm | S | 1..* | Attachment | The narrative text describing the patient's history of status. | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 3 elements
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location |
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) |
status | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. | |
category | 1..* | CodeableConcept | (USCDI) Service category | |
Slices for category | Content/Rules for all slices | |||
category:us-core | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) | |
Slices for category | Content/Rules for all slices | |||
category:PFEDomain | S | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) |
code | 1..1 | CodeableConcept | US Core Report Code | |
effective[x] | 1..1 | dateTime, Period | Diagnostically relevant time (typically the time of the procedure) | |
performer | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. | |
presentedForm | 1..* | Attachment | The narrative text describing the patient's history of status. | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location |
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) |
category:PFEDomain | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Health care event when test ordered |
effective[x] | SΣC | 1..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
performer | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) | (USCDI) Observations |
media | SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
presentedForm | S | 1..* | Attachment | The narrative text describing the patient's history of status. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG | |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
event-location | S | 0..1 | Reference(US Core Location Profile) | An extension to indicate where the documented information was collected. URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location | ||||
assistance-required | S | 0..1 | CodeableConcept | An extension to indicate the level of assistance required for a patient during an assessment. URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required Binding: LOINC Answer List LL4309-2 (extensible) | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used. Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
category:PFEDomain | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: Personal Functioning and Engagement Category Value Set (required) | ||||
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Health care event when test ordered | ||||
effective[x] | SΣC | 1..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made | ||||
performer | SΣ | 1..* | Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S) | The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization. | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
presentedForm | S | 1..* | Attachment | The narrative text describing the patient's history of status. | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
DiagnosticReport.category:PFEDomain | required | PFECategoryVS (a valid code from Personal Functioning and Engagement Category)http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs from this IG | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 3 elements
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
The syntax used to describe the interactions below is described here.
The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code = mental_functions
(how to search by reference and how to search by token)
patient
and code
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and code(s). SHOULD support search by multiple report codes. The DiagnosticReport code
parameter searches `DiagnosticReport.code only. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code = mental_functions
(how to search by reference and how to search by token and how to search by date)
The following search parameter combinations SHOULD be supported:
patient
and category
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and category mental_functions
and status final
(how to search by reference and how to search by token)
patient
and code
and date
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)