MCC eCare Plan Implementation Guide
1.0.0 - ballot United States of America flag

MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-mcc/ and changes regularly. See the Directory of published versions

Resource Profile: Multiple Chronic Condition Care Plan Diagnostic Report and Note

Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/MCCDiagnosticReportAndNote Version: 1.0.0
Active as of 2024-05-02 Computable Name: MCCDiagnosticReportAndNote

This profile constrains US Core Diagnostic Report and Note for use in the MCC FHIR Care Plan or other FHIR Care Plans.

This profile sets additional expectations for the US Core Diagnostic Report and Note Profile to search and fetch Diagnostic Reports and Notes using the DiagnosticReport resource. Diagnostic Reports are typically used for Cardiology, Radiology, and Pathology reports. In addition to the requirements set forth in US Core Diagnostic Report and Note, this derived profile is designed to add requirements to the following elements:

  • DiagnosticReport.extension:resource-pertainsToGoal (Must Support)
  • DiagnosticReport.basedOn (Must Support) to encourage linking back Care Plan activities.

Comments are welcome with respect to the pragmatic use of the “Must Support” rules defined on these elements.

No additional value sets were defined for use in this profile beyond the US Core Diagnostic Report profile.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept Please see the Diagnostic Report and Note Value Set Library for value sets that are derived from LOINC that can be used at DiagnosticReport.code element
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 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) (USCDI) Responsible Diagnostic Service
... 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 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... 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 (USCDI) registered | partial | preliminary | final +
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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept Please see the Diagnostic Report and Note Value Set Library for value sets that are derived from LOINC that can be used at DiagnosticReport.code element
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 0..1 (USCDI) 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 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... 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 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Must-Support: 2 elements

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept Please see the Diagnostic Report and Note Value Set Library for value sets that are derived from LOINC that can be used at DiagnosticReport.code element
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 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) (USCDI) Responsible Diagnostic Service
... 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 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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
... resource-pertainesToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... 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 (USCDI) registered | partial | preliminary | final +
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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept Please see the Diagnostic Report and Note Value Set Library for value sets that are derived from LOINC that can be used at DiagnosticReport.code element
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 0..1 (USCDI) 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 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... 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 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Must-Support: 2 elements

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron