US Quality Core Implementation Guide
1.0.0-ballot - STU 1 - ballot United States of America flag

US Quality Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-quality-core/ and changes regularly. See the Directory of published versions

Resource Profile: US Quality Core DiagnosticReport Profile for Laboratory Results Reporting

Official URL: http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-diagnosticreport-lab Version: 1.0.0-ballot
Standards status: Trial-use Maturity Level: 4 Computable Name: USQualityCoreDiagnosticReportLab
Other Identifiers: OID:2.16.840.1.113883.4.642.40.78.42.15

Profile of DiagnosticReport for laboratory results for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

USCDI+ Quality Element Support Expectations

Systems are expected to support this profile as part of implementing USCDI+ Quality V2 in FHIR and meeting the conformance requirements of this guide.

The following elements are specifically relevant to USCDI+ Quality V2 data classes and elements. Systems are expected to support these elements as applicable to their role in US Quality Core data exchange. See the Must Support section of this guide for more information. These elements are flagged as (USCDI+ Quality) in the formal profile views.

USCDI+ Quality Elements:

Profile element Description USCDI+ Quality Data Element(s)
category Service category Laboratory: Tests
category:LaboratorySlice Service category Laboratory: Tests
code US Core Laboratory Report Order Code Laboratory: Tests
effective[x] Diagnostically relevant time (typically the time of specimen collection) Laboratory: Specimen Collection Date and Time
issued DateTime this version was made Laboratory: Laboratory Result Report Date and Time
performer Responsible Diagnostic Service Provenance: Author
result Observations Laboratory: Values/Results
status registered | partial | preliminary | final + Laboratory: Result Status

Because this profile is derived directly or indirectly from US Core, systems are also expected to support the Must Support and Additional USCDI requirements specified by the US Core profile this profile inherits from. For more information about those requirements, refer to the US Core DiagnosticReport Profile for Laboratory Results Reporting. The Formal Views section also provides the formal summary, definitions, terminology requirements, and mandatory element requirements.

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..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... meta SΣ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource last changed
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Who analyzed and reported the conclusions and interpretations
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) Observations

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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦9.0.0 US Core v9.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport If 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-8 error DiagnosticReport effective[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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..* Reference(US Quality Core CarePlan | ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
... category 1..* CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
... code 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
... subject 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] 0..1 dateTime, Period (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
... issued 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... result 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) Observations

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... 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 0..* Reference(US Quality Core CarePlan | ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Who analyzed and reported the conclusions and interpretations
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) 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 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DiagnosticReport.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test 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
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport If 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-8 error DiagnosticReport effective[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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... meta SΣ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource last changed
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Who analyzed and reported the conclusions and interpretations
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) Observations

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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦9.0.0 US Core v9.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport If 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-8 error DiagnosticReport effective[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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..* Reference(US Quality Core CarePlan | ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
... category 1..* CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
... code 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
... subject 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] 0..1 dateTime, Period (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
... issued 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... result 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) Observations

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(9.0.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... 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 0..* Reference(US Quality Core CarePlan | ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI+ Quality) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) Service category
Slice: Unordered, Open by value:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) Service category
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Quality Core Encounter) Encounter associated with DiagnosticReport
... effective[x] SΣC 0..1 (USCDI+ Quality) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI+ Quality) DateTime this version was made
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI+ Quality) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Who analyzed and reported the conclusions and interpretations
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) 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 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DiagnosticReport.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test 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
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport If 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-8 error DiagnosticReport effective[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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Element Conformance Indicators by Profile Layer

Badges identify the profile layer where each conformance indicator is first introduced. Indicators introduced in an earlier layer remain applicable in later derived profiles.

Element conformance indicators organized by the profile layer where they are first introduced
Profile element FHIR US Core US Quality Core
meta Must Support
meta.lastUpdated Must Support
status Mandatory Must Support USCDI+ Quality
category Mandatory Must Support USCDI+ Quality
category:LaboratorySlice Mandatory Must Support USCDI+ Quality
code Mandatory Must Support USCDI+ Quality
subject Mandatory Must Support
encounter Must Support
effective[x] Must Support USCDI+ Quality
issued Must Support USCDI+ Quality
performer Must Support USCDI+ Quality
resultsInterpreter Must Support
result Must Support USCDI+ Quality
media.link Mandatory

Cardinality note: “Mandatory” means the element has a minimum cardinality greater than zero. For nested elements, the cardinality indicator applies when the containing element is present.

Mandatory US Quality Core Server Search Parameters

The searches below are the focused set identified by US Quality Core as needed to retrieve USCDI+ Quality data for quality measurement and reporting. See the US Core FHIR RESTful Search API Requirements for detailed information on requirements by search parameter type.

Because this profile derives directly or indirectly from US Core, servers SHALL also support all mandatory searches described in the US Core Server CapabilityStatement requirements for DiagnosticReport. When possible, this guide reuses mandatory searches from US Core and notes them with the EXISTING US CORE REQUIREMENT flag. While US Quality Core may restate US Core requirements to highlight searches directly relevant to USCDI+ Quality data access, US Core requirements not restated here remain applicable.

See the US Quality Core Server CapabilityStatement for complete requirements for the underlying DiagnosticReport resource and Search Requirement Selection for how this focused set was selected.

Servers supporting this profile SHALL support the following search parameters and search parameter combinations:

  1. SHALL support searching for all DiagnosticReport resources for a patient using the patient search parameter. EXISTING US CORE REQUIREMENT

    GET [base]/DiagnosticReport?patient={Patient/}[id]

    Example:

    GET [base]/DiagnosticReport?patient=Patient/example

    Implementation Notes: Fetches a bundle of US Quality Core DiagnosticReport Profile for Laboratory Results Reporting resources matching the specified search criteria. See how to search by reference.

    Rationale for inclusion: Supports patient-scoped retrieval of DiagnosticReport resources for USCDI+ Quality workflows.

  2. SHALL support searching for all DiagnosticReport resources for a patient using the combination of the patient and category search parameters. EXISTING US CORE REQUIREMENT

    • Including optional support for OR search on category (e.g.category={system|}[search_code],{system|}[search_code],...).

    GET [base]/DiagnosticReport?patient={Patient/}[id]&category={system|}[search_code]

    Example:

    GET [base]/DiagnosticReport?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/v2-0074|LAB

    Implementation Notes: Fetches a bundle of US Quality Core DiagnosticReport Profile for Laboratory Results Reporting resources matching the specified search criteria. See how to search by reference and how to search by token.

    Rationale for inclusion: Supports patient-scoped retrieval of DiagnosticReport resources filtered by category for USCDI+ Quality workflows.

  3. SHALL support searching for all DiagnosticReport resources for a patient using the combination of the patient, category, and date search parameters. EXISTING US CORE REQUIREMENT

    • Including optional support for OR search on category (e.g.category={system|}[search_code],{system|}[search_code],...).

    • Including optional support for AND search on date (e.g.date=[date]&date=[date]&...).

    • Including support for these date comparators: "gt", "lt", "ge", "le".

    GET [base]/DiagnosticReport?patient={Patient/}[id]&category={system|}[search_code]&date={gt|lt|ge|le}[dateTime]

    Example:

    GET [base]/DiagnosticReport?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/v2-0074|LAB&date=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of US Quality Core DiagnosticReport Profile for Laboratory Results Reporting resources matching the specified search criteria. See how to search by reference, how to search by token, and how to search by date.

    Rationale for inclusion: Supports patient-scoped retrieval of DiagnosticReport resources filtered by category and date so quality workflows can constrain results to relevant reporting periods.

  4. SHALL support searching for all DiagnosticReport resources for a patient using the combination of the patient and code search parameters. EXISTING US CORE REQUIREMENT

    • Including optional support for OR search on code (e.g.code={system|}[search_code],{system|}[search_code],...).

    GET [base]/DiagnosticReport?patient={Patient/}[id]&code={system|}[search_code]

    Example:

    GET [base]/DiagnosticReport?patient=Patient/example&code=http://loinc.org|58410-2

    Implementation Notes: Fetches a bundle of US Quality Core DiagnosticReport Profile for Laboratory Results Reporting resources matching the specified search criteria. See how to search by reference and how to search by token.

    Rationale for inclusion: Supports patient-scoped retrieval of DiagnosticReport resources filtered by code for USCDI+ Quality workflows.