Resumen Clínico del Paciente de Chile
0.7.0-ci-build - STU3
Resumen Clínico del Paciente de Chile
0.7.0-ci-build - STU3
Resumen Clínico del Paciente de Chile, published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.7.0-ci-build 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
| Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/DiagnosticReport-cl-ips | Version: 0.7.0-ci-build | |||
| Standards status: Draft | Maturity Level: 1 | Computable Name: DiagnosticReportClIps | ||
| Other Identifiers: OID:2.16.840.1.113883.2.22.40.13.42.6 | ||||
Reporte resultado de un o varios estudios para diagnosticar una enfermedad. Este perfil es el simil al DiagnosticReport(IPS).
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final (extensions allowed) | |
 category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | |
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | |
  subject |
1..1 | Reference(Paciente | Group) | El sujeto del informe, generalmente, pero no siempre, es el paciente | |
  reference |
C | 1..1 | string | Referencia literal, interna o url absoluta |
 effective[x] |
1..1 | Tiempo o periodo de tiempo clínicamente relevante para el informe | ||
 effective[x]All Types |
Content/Rules for all Types | |||
  Slices for extension |
Content/Rules for all slices | |||
  extension:data-absent-reason |
0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
  extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||
| 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 | |||
| performer |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
 result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
| 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()
|
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
DiagnosticReport | |||
| status |
1..1 | code | registered | partial | preliminary | final + Required Pattern: final (extensions allowed) | |
| category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto | |
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto | |
| subject |
1..1 | Reference(Paciente | Group) | El sujeto del informe, generalmente, pero no siempre, es el paciente | |
| reference |
1..1 | string | Referencia literal, interna o url absoluta | |
| effective[x] |
1..1 | dateTime, Period | Tiempo o periodo de tiempo clínicamente relevante para el informe | |
 Slices for extension |
Content/Rules for all slices | |||
| extension:data-absent-reason |
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 |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| 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 |
0..* | Identifier | Business identifier for report | |||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final (extensions allowed) | |||||
| category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | |||||
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | |||||
| subject |
1..1 | Reference(Paciente | 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 |
C | 1..1 | string | Referencia literal, interna o url absoluta | ||||
| type |
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 |
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| encounter |
0..1 | Reference(Encounter) | Health care event when test ordered | |||||
| effective[x] |
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 | |||||
| extension:data-absent-reason |
0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||
| 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 |
0..1 | instant | DateTime this version was made | |||||
| performer |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |||||
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |||||
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |||||
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |||||
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |||||
| media |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
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 | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
| 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()
|
This structure is derived from DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final (extensions allowed) | |
| category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | |
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | |
| subject |
1..1 | Reference(Paciente | Group) | El sujeto del informe, generalmente, pero no siempre, es el paciente | |
| reference |
C | 1..1 | string | Referencia literal, interna o url absoluta |
| effective[x] |
1..1 | Tiempo o periodo de tiempo clínicamente relevante para el informe | ||
| effective[x]All Types |
Content/Rules for all Types | |||
| Slices for extension |
Content/Rules for all slices | |||
| extension:data-absent-reason |
0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||
| 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 | |||
| performer |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
| 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()
|
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
DiagnosticReport | |||
| status |
1..1 | code | registered | partial | preliminary | final + Required Pattern: final (extensions allowed) | |
| category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto | |
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto | |
| subject |
1..1 | Reference(Paciente | Group) | El sujeto del informe, generalmente, pero no siempre, es el paciente | |
| reference |
1..1 | string | Referencia literal, interna o url absoluta | |
| effective[x] |
1..1 | dateTime, Period | Tiempo o periodo de tiempo clínicamente relevante para el informe | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:data-absent-reason |
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 |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| 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 |
0..* | Identifier | Business identifier for report | |||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final (extensions allowed) | |||||
| category |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | |||||
| code |
1..1 | CodeableConcept | Concepto - referencia a una terminología o sólo texto Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | |||||
| subject |
1..1 | Reference(Paciente | 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 |
C | 1..1 | string | Referencia literal, interna o url absoluta | ||||
| type |
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 |
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| encounter |
0..1 | Reference(Encounter) | Health care event when test ordered | |||||
| effective[x] |
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 | |||||
| extension:data-absent-reason |
0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||
| 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 |
0..1 | instant | DateTime this version was made | |||||
| performer |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Servicio de Diagnóstico Responsable | |||||
| resultsInterpreter |
0..* | Reference(Prestador Individual | Función o Rol de Prestador Individual | Organización | CareTeam) | Interprete primario del resultado | |||||
| specimen |
0..* | Reference(Muestra) | Muestras en las que se basa este informe | |||||
| Slices for result |
0..* | Reference(CL Observación) | Observaciones Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| result:observacion-resultados |
0..* | Reference(Observación Resultado: Laboratorio/Patología | Observación Resultado: Imagenológico) | Observations | |||||
| imagingStudy |
0..* | Reference(Estudio de Imagenología) | Referencia a los detalles completos de las imágenes asociadas con el informe diagnóstico | |||||
| media |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
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 | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
| 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()
|
This structure is derived from DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron