Resumen Clínico de Paciente de Chile (IPS-CL)
0.3.0-ballot - STU2 Ballot 1 Chile flag

Resumen Clínico de Paciente de Chile (IPS-CL), published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.3.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/IPS-CL/ and changes regularly. See the Directory of published versions

Resource Profile: Reporte Diagnóstico (IPS-CL)

Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/DiagnosticReport-cl-ips Version: 0.3.0-ballot
Standards status: Draft Maturity Level: 1 Computable Name: DiagnosticReportClIps

Reporte resultado de un o varios estudios para diagnosticar una enfermedad. Este perfil es el simil al DiagnosticReport(IPS).

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport DiagnosticReport
... status S 1..1 code registered | partial | preliminary | final +
Required Pattern: final
... category S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
.... reference S 1..1 string Referencia literal, interna o url absoluta
... effective[x] S 1..1 dateTime, Period Tiempo o periodo de tiempo clínicamente relevante para el informe
.... Slices for extension Content/Rules for all slices
..... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
...... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra

... performer S 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
... resultsInterpreter S 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


ele-1: All FHIR elements must have a @value or children
Required Pattern: final
... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.


ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(Paciente (IPS-CL) | Group) El sujeto del informe, generalmente, pero no siempre, es el paciente
ele-1: All FHIR elements must have a @value or children
.... reference SΣC 1..1 string Referencia literal, interna o url absoluta
ele-1: All FHIR elements must have a @value or children
... effective[x] SΣ 1..1 Tiempo o periodo de tiempo clínicamente relevante para el informe
ele-1: All FHIR elements must have a @value or children
.... effective[x]All Types Content/Rules for all Types
..... Slices for extension Content/Rules for all slices
...... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
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/StructureDefinition/data-absent-reason"
....... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra


ele-1: All FHIR elements must have a @value or children
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
ele-1: All FHIR elements must have a @value or children
... resultsInterpreter SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
ele-1: All FHIR elements must have a @value or children
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
ele-1: All FHIR elements must have a @value or children
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
ele-1: All FHIR elements must have a @value or children
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
ele-1: All FHIR elements must have a @value or children
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Required Pattern: final
... category S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Paciente (IPS-CL) | Group) El sujeto del informe, generalmente, pero no siempre, es el paciente
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Referencia literal, interna o url absoluta
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣ 1..1 Tiempo o periodo de tiempo clínicamente relevante para el informe
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
....... id 0..1 id Unique id for inter-element referencing
....... extension 0..0
....... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
....... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra

.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
... resultsInterpreter SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico
... 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

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
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()

This structure is derived from DiagnosticReport

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport DiagnosticReport
... status S 1..1 code registered | partial | preliminary | final +
Required Pattern: final
... category S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
.... reference S 1..1 string Referencia literal, interna o url absoluta
... effective[x] S 1..1 dateTime, Period Tiempo o periodo de tiempo clínicamente relevante para el informe
.... Slices for extension Content/Rules for all slices
..... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
...... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra

... performer S 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
... resultsInterpreter S 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


ele-1: All FHIR elements must have a @value or children
Required Pattern: final
... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.


ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(Paciente (IPS-CL) | Group) El sujeto del informe, generalmente, pero no siempre, es el paciente
ele-1: All FHIR elements must have a @value or children
.... reference SΣC 1..1 string Referencia literal, interna o url absoluta
ele-1: All FHIR elements must have a @value or children
... effective[x] SΣ 1..1 Tiempo o periodo de tiempo clínicamente relevante para el informe
ele-1: All FHIR elements must have a @value or children
.... effective[x]All Types Content/Rules for all Types
..... Slices for extension Content/Rules for all slices
...... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
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/StructureDefinition/data-absent-reason"
....... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra


ele-1: All FHIR elements must have a @value or children
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
ele-1: All FHIR elements must have a @value or children
... resultsInterpreter SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
ele-1: All FHIR elements must have a @value or children
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
ele-1: All FHIR elements must have a @value or children
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
ele-1: All FHIR elements must have a @value or children
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
ele-1: All FHIR elements must have a @value or children
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Required Pattern: final
... category S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S 1..1 CodeableConceptIPS Concepto - referencia a una terminología o sólo texto
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Paciente (IPS-CL) | Group) El sujeto del informe, generalmente, pero no siempre, es el paciente
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Referencia literal, interna o url absoluta
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣ 1..1 Tiempo o periodo de tiempo clínicamente relevante para el informe
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... data-absent-reason S 0..1 (Complex) Motivo por el cual no se encuentra el dato
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
....... id 0..1 id Unique id for inter-element referencing
....... extension 0..0
....... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
....... value[x] 1..1 code Value of extension
Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra

.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Servicio de Diagnóstico Responsable
... resultsInterpreter SΣ 0..* Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) Interprete primario del resultado
... specimen S 0..* Reference(Muestra (IPS-CL)) Muestras en las que se basa este informe
... Slices for result S 0..* Reference(CL Observación) Observaciones
Slice: Unordered, Open by profile:resolve()
.... result:observacion-resultados S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) Observations
... imagingStudy 0..* Reference(Estudio de Imagenología (IPS-Cl)) Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico
... 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

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.effective[x].extension:data-absent-reason.value[x]requiredDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
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()

This structure is derived from DiagnosticReport

 

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