HL7 Laboratory Report
1.0.0-ballot - STU 1 Ballot International flag

HL7 Laboratory Report, published by HL7 International / Orders and Observations. 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/uv-lab-rep-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Composition: Laboratory Report

Official URL: http://hl7.org/fhir/uv/lab-report/StructureDefinition/Composition-uv-lab Version: 1.0.0-ballot
Standards status: Trial-use Maturity Level: 2 Computable Name: CompositionLabReportUv

Clinical document used to represent a Laboratory Report for the scope of the HL7 UV Lab project.

Based on order

This version of the guide uses the HL7 basedOn-order-or-requisition extension to link this Composition to the to the order or requisition.

Implementers are invited to provide their feedback about the possible adoption of the standard extension event-basedOn for referring the order fulfilled.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition Laboratory Report composition
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: 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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... text 0..1 Narrative Narrative text
ele-1: All FHIR elements must have a @value or children
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... basedOn-order-or-requisition 0..* (Complex) Document Based On Order
URL: http://hl7.org/fhir/uv/lab-report/StructureDefinition/composition-basedOn-order-or-requisition
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/uv/lab-report/StructureDefinition/composition-basedOn-order-or-requisition"
..... Slices for value[x] 0..1 Value of extension
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
...... valueIdentifier Identifier
...... valueReference Reference(ServiceRequest)
...... value[x]:valueReference 0..1 Reference(ServiceRequest: Laboratory Order) Value of extension
ele-1: All FHIR elements must have a @value or children
.... information-recipient 0..* (Complex) Information recipient
URL: http://hl7.org/fhir/uv/lab-report/StructureDefinition/information-recipient
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/uv/lab-report/StructureDefinition/information-recipient"
..... value[x] 0..1 Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) Value of extension
ele-1: All FHIR elements must have a @value or children
.... diagnosticReport-reference 0..1 (Complex) Document DiagnosticReport Reference
URL: http://hl7.org/fhir/uv/lab-report/StructureDefinition/composition-diagnosticReportReference
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/uv/lab-report/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(DiagnosticReport: Laboratory Report) Value of extension
ele-1: All FHIR elements must have a @value or children
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
ele-1: All FHIR elements must have a @value or children
... identifier Σ 0..1 Identifier Report identifier
ele-1: All FHIR elements must have a @value or children
... status ?!Σ 1..1 code Status of the Report
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


ele-1: All FHIR elements must have a @value or children
... type Σ 1..1 CodeableConceptIPS Type of (Laboratory) Report
Binding: Laboratory Report Types (preferred)
ele-1: All FHIR elements must have a @value or children
... Slices for category Σ 0..* CodeableConceptIPS Report Category
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


ele-1: All FHIR elements must have a @value or children
.... category:studyType Σ 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
ele-1: All FHIR elements must have a @value or children
.... category:specialty Σ 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
ele-1: All FHIR elements must have a @value or children
... subject Σ 1..1 Reference(Patient: Person | Patient: Animal | Group | Location | Device) Who and/or what this report is about
ele-1: All FHIR elements must have a @value or children
... encounter Σ 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
ele-1: All FHIR elements must have a @value or children
... date Σ 1..1 dateTime Composition editing time
ele-1: All FHIR elements must have a @value or children
... author Σ 1..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the Laboratory Report
ele-1: All FHIR elements must have a @value or children
... title Σ 1..1 string Laboratory Report
ele-1: All FHIR elements must have a @value or children
... attester 0..* BackboneElement Attests the report accuracy
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... mode 1..1 code The type of attestation
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


ele-1: All FHIR elements must have a @value or children
.... time 0..1 dateTime When the report was attested by the party
ele-1: All FHIR elements must have a @value or children
.... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the report
ele-1: All FHIR elements must have a @value or children
... event Σ 0..* BackboneElement The laboratory service(s) being documented
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... code Σ 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


ele-1: All FHIR elements must have a @value or children
.... period Σ 0..1 Period Period of time covered by the documentation
ele-1: All FHIR elements must have a @value or children
.... detail Σ 0..* Reference(Resource) The laboratory service(s) being documented
ele-1: All FHIR elements must have a @value or children
... Slices for section C 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by exists:$this.section, exists:$this.entry
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... title 1..1 string Label for section (e.g. for ToC)
ele-1: All FHIR elements must have a @value or children
..... code 1..1 CodeableConceptIPS Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


ele-1: All FHIR elements must have a @value or children
.... section:lab-no-subsections C 0..* BackboneElement Variant 1: Laboratory Report section with entries and no sub-sections
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: Laboratory Study Types (preferred)
ele-1: All FHIR elements must have a @value or children
..... text C 0..1 Narrative Text summary of the section, for human interpretation.
ele-1: All FHIR elements must have a @value or children
..... entry C 1..* Reference(Observation Results: laboratory) A reference to data that supports this section
ele-1: All FHIR elements must have a @value or children
.... section:lab-subsections C 0..* BackboneElement Variant 2: Laboratory Report section with one to many subsections Laboratory Report Item
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: Laboratory Study Types (preferred)
ele-1: All FHIR elements must have a @value or children
..... section C 1..* BackboneElement Nested Section
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... title 1..1 string Label for section (e.g. for ToC)
ele-1: All FHIR elements must have a @value or children
...... code 1..1 CodeableConceptIPS Classification of section (recommended)
Binding: Laboratory Study Types (preferred)
ele-1: All FHIR elements must have a @value or children
...... text C 0..1 Narrative Text summary of the section, for human interpretation.
ele-1: All FHIR elements must have a @value or children
...... entry C 1..* Reference(Observation Results: laboratory) A reference to data that supports this section
ele-1: All FHIR elements must have a @value or children
.... section:annotations C 0..* BackboneElement Annotation comment
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
..... text C 1..1 Narrative Text summary of the section, for human interpretation
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredLabReportTypesVs
http://hl7.org/fhir/uv/lab-report/ValueSet/reportType-uv-lab
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.category:studyTyperequiredLabStudyTypesVs
http://hl7.org/fhir/uv/lab-report/ValueSet/studyType-uv-lab
from this IG
Composition.category:specialtyrequiredLabSpecialtyVs
http://hl7.org/fhir/uv/lab-report/ValueSet/specialty-uv-lab
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:lab-no-subsections.codepreferredLabStudyTypesVs
http://hl7.org/fhir/uv/lab-report/ValueSet/studyType-uv-lab
from this IG
Composition.section:lab-subsections.codepreferredLabStudyTypesVs
http://hl7.org/fhir/uv/lab-report/ValueSet/studyType-uv-lab
from this IG
Composition.section:lab-subsections.section.codepreferredLabStudyTypesVs
http://hl7.org/fhir/uv/lab-report/ValueSet/studyType-uv-lab
from this IG
Composition.section:annotations.codeexamplePattern: LOINC Code 48767-8
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotationsA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotationsA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA 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()

 

Other representations of profile: CSV, Excel, Schematron