PACIO Personal Functioning and Engagement Implementation Guide
3.0.0-ballot - STU 3 Ballot United States of America flag

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 3.0.0-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

Resource Profile: Personal Functioning and Engagement Diagnostic Report Note Exchange Profile

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-diagnostic-report-note-exchange Version: 3.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: PFEDiagnosticReportNoteExchange
Other Identifiers: OID:2.16.840.1.113883.4.642.40.67.42.13

An exchange of post-acute care diagonistic report notes for a patient. This profile is used for exchanging diagnostic report notes, as opposed to laboratory notes.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: USCoreDiagnosticReportCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreDiagnosticReportCategory (9.0.0) Min Binding
Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: USCoreNonLaboratoryCodes (9.0.0) (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group | US Core Device Profile | US Core Location Profile(9.0.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile(9.0.0)) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) S | US Core PractitionerRole Profile(9.0.0) | US Core CareTeam Profile(9.0.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) | PractitionerRole | US Core CareTeam Profile(9.0.0)) Primary result interpreter
... result S 0..* Reference(US Core Observation Clinical Result Profile(9.0.0) S | US Core Laboratory Result Observation Profile(9.0.0) | Observation) Observations
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📍9.0.0 US Core v9.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📍9.0.0 US Core v9.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: USCoreDiagnosticReportCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreDiagnosticReportCategory (9.0.0) Min Binding
Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: USCoreNonLaboratoryCodes (9.0.0) (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group | US Core Device Profile | US Core Location Profile(9.0.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile(9.0.0)) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) S | US Core PractitionerRole Profile(9.0.0) | US Core CareTeam Profile(9.0.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) | PractitionerRole | US Core CareTeam Profile(9.0.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Core Observation Clinical Result Profile(9.0.0) S | US Core Laboratory Result Observation Profile(9.0.0) | Observation) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media Σ 0..* BackboneElement 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 Σ 1..1 Reference(Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📍9.0.0 US Core v9.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📍9.0.0 US Core v9.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Summary

Must-Support: 3 elements

Maturity: 3

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: USCoreDiagnosticReportCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreDiagnosticReportCategory (9.0.0) Min Binding
Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: USCoreNonLaboratoryCodes (9.0.0) (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group | US Core Device Profile | US Core Location Profile(9.0.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile(9.0.0)) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) S | US Core PractitionerRole Profile(9.0.0) | US Core CareTeam Profile(9.0.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) | PractitionerRole | US Core CareTeam Profile(9.0.0)) Primary result interpreter
... result S 0..* Reference(US Core Observation Clinical Result Profile(9.0.0) S | US Core Laboratory Result Observation Profile(9.0.0) | Observation) Observations
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📍9.0.0 US Core v9.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📍9.0.0 US Core v9.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results

doco Documentation for this format

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: USCoreDiagnosticReportCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreDiagnosticReportCategory (9.0.0) Min Binding
Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: USCoreNonLaboratoryCodes (9.0.0) (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group | US Core Device Profile | US Core Location Profile(9.0.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile(9.0.0)) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) S | US Core PractitionerRole Profile(9.0.0) | US Core CareTeam Profile(9.0.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile(9.0.0) S | US Core Organization Profile(9.0.0) | PractitionerRole | US Core CareTeam Profile(9.0.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Core Observation Clinical Result Profile(9.0.0) S | US Core Laboratory Result Observation Profile(9.0.0) | Observation) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media Σ 0..* BackboneElement 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 Σ 1..1 Reference(Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📍9.0.0 US Core v9.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📍9.0.0 US Core v9.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Summary

Must-Support: 3 elements

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron