Lithuanian Cervical Cancer Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Cervical Cancer Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-cervical/ and changes regularly. See the Directory of published versions

Resursų profilis: DiagnosticReport: Colposcopy

Oficialus URL: https://hl7.lt/fhir/cervical/StructureDefinition/colposcopy-diagnostic-report-lt-cervical Versija: 0.0.1
Mašiniškai apdorojamas pavadinimas: ColposcopyDiagnosticReportLtCervical

Diagnostic report summarizing findings and procedures performed during colposcopy in the Lithuanian cervical cancer screening pathway.

Usages:

You can also check for usages in the FHIR IG Statistics

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NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: dgr-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... basedOn S 0..* Reference(ServiceRequestLt(0.3.0) | CarePlanLt(0.3.0) | ImmunizationRecommendation | MedicationRequest | NutritionOrder) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..1 CodeableConcept Service category
Binding: Hl7VSDiagnosticServiceSectionId (3.0.0) (preferred)

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/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
..... 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 Name/Code for this diagnostic report
Binding: ReportCode (1.0.0) (preferred)
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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(EncounterLt(0.3.0)) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant DateTime this version was made
... performer SΣ 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result SC 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... note S 0..* Annotation Comments about the diagnostic report
... study S 0..* Reference(ImagingStudyLt(0.3.0) | GenomicStudy) Reference to full details of an analysis associated with the diagnostic report
... supportingInfo S 0..* BackboneElement Additional information supporting the diagnostic report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... type 1..1 CodeableConcept Supporting information role code
Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference
... composition SC 0..1 Reference(CompositionLt(0.3.0)) Reference to a Composition resource for the DiagnosticReport structure
... conclusion S 0..1 markdown Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required Diagnostic Report Status 📍5.0.0 FHIR Std.
DiagnosticReport.category Base preferred hl7VS-diagnosticServiceSectionId 📍3.0.0 THO v7.1
DiagnosticReport.code Base preferred Report Code 📍1.0.0 HL7 Europe IG Snapshot v0.0
DiagnosticReport.supportingInfo.​type Base example hl7VS-VS-observationType 📍3.0.0 THO v7.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dgr-1 error DiagnosticReport When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 DiagnosticReport.implicitRules, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error DiagnosticReport.modifierExtension, DiagnosticReport.supportingInfo.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... category 1..1 CodeableConcept Service category
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://terminology.hl7.org/CodeSystem/observation-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
... code 1..1 CodeableConcept Name/Code for this diagnostic report
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://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
... subject 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... performer 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... supportingInfo
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: dgr-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... 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
Constraints: ext-1
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... identifier SΣ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(ServiceRequestLt(0.3.0) | CarePlanLt(0.3.0) | ImmunizationRecommendation | MedicationRequest | NutritionOrder) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..1 CodeableConcept Service category
Binding: Hl7VSDiagnosticServiceSectionId (3.0.0) (preferred)

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/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
..... 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 Name/Code for this diagnostic report
Binding: ReportCode (1.0.0) (preferred)
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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(EncounterLt(0.3.0)) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant DateTime this version was made
... performer SΣ 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result SC 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... note S 0..* Annotation Comments about the diagnostic report
... study S 0..* Reference(ImagingStudyLt(0.3.0) | GenomicStudy) Reference to full details of an analysis associated with the diagnostic report
... supportingInfo S 0..* BackboneElement Additional information supporting the diagnostic report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... type 1..1 CodeableConcept Supporting information role code
Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference
... media Σ 0..* BackboneElement Key images or data associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... comment 0..1 string Comment about the image or data (e.g. explanation)
.... link Σ 1..1 Reference(DocumentReference) Reference to the image or data source
... composition SC 0..1 Reference(CompositionLt(0.3.0)) Reference to a Composition resource for the DiagnosticReport structure
... conclusion S 0..1 markdown Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings
... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base required All Languages 📍5.0.0 FHIR Std.
DiagnosticReport.status Base required Diagnostic Report Status 📍5.0.0 FHIR Std.
DiagnosticReport.category Base preferred hl7VS-diagnosticServiceSectionId 📍3.0.0 THO v7.1
DiagnosticReport.code Base preferred Report Code 📍1.0.0 HL7 Europe IG Snapshot v0.0
DiagnosticReport.supportingInfo.​type Base example hl7VS-VS-observationType 📍3.0.0 THO v7.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dgr-1 error DiagnosticReport When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 DiagnosticReport.meta, DiagnosticReport.implicitRules, DiagnosticReport.language, DiagnosticReport.text, DiagnosticReport.extension, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.media, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension, DiagnosticReport.media.comment, DiagnosticReport.media.link, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode, DiagnosticReport.presentedForm All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error DiagnosticReport.extension, DiagnosticReport.modifierExtension, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Pagrindinių elementų peržiūra

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: dgr-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... basedOn S 0..* Reference(ServiceRequestLt(0.3.0) | CarePlanLt(0.3.0) | ImmunizationRecommendation | MedicationRequest | NutritionOrder) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..1 CodeableConcept Service category
Binding: Hl7VSDiagnosticServiceSectionId (3.0.0) (preferred)

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/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
..... 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 Name/Code for this diagnostic report
Binding: ReportCode (1.0.0) (preferred)
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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(EncounterLt(0.3.0)) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant DateTime this version was made
... performer SΣ 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result SC 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... note S 0..* Annotation Comments about the diagnostic report
... study S 0..* Reference(ImagingStudyLt(0.3.0) | GenomicStudy) Reference to full details of an analysis associated with the diagnostic report
... supportingInfo S 0..* BackboneElement Additional information supporting the diagnostic report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... type 1..1 CodeableConcept Supporting information role code
Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference
... composition SC 0..1 Reference(CompositionLt(0.3.0)) Reference to a Composition resource for the DiagnosticReport structure
... conclusion S 0..1 markdown Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required Diagnostic Report Status 📍5.0.0 FHIR Std.
DiagnosticReport.category Base preferred hl7VS-diagnosticServiceSectionId 📍3.0.0 THO v7.1
DiagnosticReport.code Base preferred Report Code 📍1.0.0 HL7 Europe IG Snapshot v0.0
DiagnosticReport.supportingInfo.​type Base example hl7VS-VS-observationType 📍3.0.0 THO v7.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dgr-1 error DiagnosticReport When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 DiagnosticReport.implicitRules, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error DiagnosticReport.modifierExtension, DiagnosticReport.supportingInfo.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Skirtumų rinkinių peržiūra

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... category 1..1 CodeableConcept Service category
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://terminology.hl7.org/CodeSystem/observation-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
... code 1..1 CodeableConcept Name/Code for this diagnostic report
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://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
... subject 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... performer 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... supportingInfo
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference

doco Documentation for this format

Momentinės kopijos peržiūraView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* DiagnosticReportLt(0.3.0) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: dgr-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... 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
Constraints: ext-1
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... identifier SΣ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(ServiceRequestLt(0.3.0) | CarePlanLt(0.3.0) | ImmunizationRecommendation | MedicationRequest | NutritionOrder) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..1 CodeableConcept Service category
Binding: Hl7VSDiagnosticServiceSectionId (3.0.0) (preferred)

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/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
..... 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 Name/Code for this diagnostic report
Binding: ReportCode (1.0.0) (preferred)
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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 392003006
..... display 1..1 string Representation defined by the system
Fixed Value: Colposcopy (procedure)
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(PatientLt(0.3.0)) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(EncounterLt(0.3.0)) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant DateTime this version was made
... performer SΣ 1..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(PractitionerLt(0.3.0) | PractitionerRoleLt(0.3.0)) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result SC 0..* Reference(Observation: Colposcopy Findings(0.0.1)) Observations
... note S 0..* Annotation Comments about the diagnostic report
... study S 0..* Reference(ImagingStudyLt(0.3.0) | GenomicStudy) Reference to full details of an analysis associated with the diagnostic report
... supportingInfo S 0..* BackboneElement Additional information supporting the diagnostic report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... type 1..1 CodeableConcept Supporting information role code
Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
.... reference 1..1 Reference(Procedure: Colposcopy(0.0.1) | Procedure: Cervical Biopsy during Colposcopy(0.0.1)) Supporting information reference
... media Σ 0..* BackboneElement Key images or data associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... comment 0..1 string Comment about the image or data (e.g. explanation)
.... link Σ 1..1 Reference(DocumentReference) Reference to the image or data source
... composition SC 0..1 Reference(CompositionLt(0.3.0)) Reference to a Composition resource for the DiagnosticReport structure
... conclusion S 0..1 markdown Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings
... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base required All Languages 📍5.0.0 FHIR Std.
DiagnosticReport.status Base required Diagnostic Report Status 📍5.0.0 FHIR Std.
DiagnosticReport.category Base preferred hl7VS-diagnosticServiceSectionId 📍3.0.0 THO v7.1
DiagnosticReport.code Base preferred Report Code 📍1.0.0 HL7 Europe IG Snapshot v0.0
DiagnosticReport.supportingInfo.​type Base example hl7VS-VS-observationType 📍3.0.0 THO v7.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dgr-1 error DiagnosticReport When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 DiagnosticReport.meta, DiagnosticReport.implicitRules, DiagnosticReport.language, DiagnosticReport.text, DiagnosticReport.extension, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.media, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension, DiagnosticReport.media.comment, DiagnosticReport.media.link, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode, DiagnosticReport.presentedForm All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error DiagnosticReport.extension, DiagnosticReport.modifierExtension, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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