Imaging Diagnostic Report
0.0.1-current - ci-build
Imaging Diagnostic Report
0.0.1-current - ci-build
Imaging Diagnostic Report, published by IHE Radiology Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/RAD.IDR/ and changes regularly. See the Directory of published versions
| Official URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/imaging-diagnosticreport | Version: 0.0.1-current | |||
| Draft as of 2024-06-25 | Computable Name: ImagingDiagnosticReport | |||
IHE Imaging Diagnostic Report (IDR) profile on DiagnosticReport
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG |
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  DiagnosticReport |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports dgr-1: 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` | ||||
  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
| |||||
| text |
S | 1..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
   comparison |
S | 0..* | Reference(Comaprison studies) | IDR DiagnosticReport Comparison Study URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrComparisonStudy | ||||
| patientHistory |
S | 0..* | Reference(Past diagnosis of patient in Imaging Diagnostic Report | Relevant observations of patient | Past procedure performed on patient in Imaging Diagnostic Report | Family member medical history of patient in Imaging Diagnostic Report) | Patient history items selected by radiologist URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrPatientHistory | ||||
| procedure |
S | 0..* | Reference(Procedure and material information in Imaging Diagnostic Report) | Imaging procedure URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrImagingProcedure | ||||
| impression |
S | 1..* | Reference(Impression as Condition | Findings or Impressions in Diagnostic Reports) | Impression URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrImpression | ||||
| recommendation |
S | 0..* | Reference(Recommendation) | Recommendations URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrRecommendation | ||||
| communication |
S | 0..* | Reference(Communications for Imaging Diagnostic Reports) | Communications with other care providers URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrCommunication | ||||
 approval |
S | 0..* | Reference(Signature) | Attestation URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrSignature | ||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
 Slices for basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:resolve() | ||||
| basedOn:serviceRequest |
0..* | Reference(Imaging ServiceRequest) | The order for imaging. | |||||
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: IDR DiagnosticReport.status ValueSet (required) | ||||
| category |
SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports | ||||
 subject |
SΣ | 1..1 | Reference(IDR Patient) | The imaged patient | ||||
 effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
 effectivePeriod |
Period | |||||||
| issued |
Σ | 1..1 | instant | DateTime that this diagnostic report is published. | ||||
| Slices for performer |
Σ | 1..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service Slice: Unordered, Open by type:resolve() | ||||
| performer:organization |
Σ | 1..* | Reference(Organization) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 1..* | Reference(Practitioner | PractitionerRole) | Primary intepreter of results | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
SC | 0..* | Reference(Findings or Impressions in Diagnostic Reports) | Findings | ||||
| study |
S | 1..* | Reference(IDR ImagingStudy) | Study subject to this report | ||||
| supportingInfo |
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 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report. | |||||
| reference |
1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference | |||||
| conclusion |
S | 0..1 | markdown | Clinical conclusion (interpretation) of test results | ||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | |
| DiagnosticReport.supportingInfo.type | example | Hl7VSVSObservationTypehttp://terminology.hl7.org/ValueSet/v2-0936 | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
This structure is derived from DiagnosticReport
Summary
Mandatory: 10 elements
Must-Support: 14 elements
Prohibited: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG |
Key Elements View
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports dgr-1: 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` | ||||
| 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
| |||||
| text |
S | 1..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| comparison |
S | 0..* | Reference(Comaprison studies) | IDR DiagnosticReport Comparison Study URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrComparisonStudy | ||||
| patientHistory |
S | 0..* | Reference(Past diagnosis of patient in Imaging Diagnostic Report | Relevant observations of patient | Past procedure performed on patient in Imaging Diagnostic Report | Family member medical history of patient in Imaging Diagnostic Report) | Patient history items selected by radiologist URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrPatientHistory | ||||
| procedure |
S | 0..* | Reference(Procedure and material information in Imaging Diagnostic Report) | Imaging procedure URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrImagingProcedure | ||||
| impression |
S | 1..* | Reference(Impression as Condition | Findings or Impressions in Diagnostic Reports) | Impression URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrImpression | ||||
| recommendation |
S | 0..* | Reference(Recommendation) | Recommendations URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrRecommendation | ||||
| communication |
S | 0..* | Reference(Communications for Imaging Diagnostic Reports) | Communications with other care providers URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrCommunication | ||||
| approval |
S | 0..* | Reference(Signature) | Attestation URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrSignature | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| Slices for basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:resolve() | ||||
| basedOn:serviceRequest |
0..* | Reference(Imaging ServiceRequest) | The order for imaging. | |||||
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: IDR DiagnosticReport.status ValueSet (required) | ||||
| category |
SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports | ||||
| subject |
SΣ | 1..1 | Reference(IDR Patient) | The imaged patient | ||||
| effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
Σ | 1..1 | instant | DateTime that this diagnostic report is published. | ||||
| Slices for performer |
Σ | 1..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service Slice: Unordered, Open by type:resolve() | ||||
| performer:organization |
Σ | 1..* | Reference(Organization) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 1..* | Reference(Practitioner | PractitionerRole) | Primary intepreter of results | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
SC | 0..* | Reference(Findings or Impressions in Diagnostic Reports) | Findings | ||||
| study |
S | 1..* | Reference(IDR ImagingStudy) | Study subject to this report | ||||
| supportingInfo |
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 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report. | |||||
| reference |
1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference | |||||
| conclusion |
S | 0..1 | markdown | Clinical conclusion (interpretation) of test results | ||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| DiagnosticReport.status | required | IDRDiagnosticReportStatusVShttps://profiles.ihe.net/RAD/IDR/ValueSet/idr-diagnostic-report-status-vsfrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | |
| DiagnosticReport.supportingInfo.type | example | Hl7VSVSObservationTypehttp://terminology.hl7.org/ValueSet/v2-0936 | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
This structure is derived from DiagnosticReport
Summary
Mandatory: 10 elements
Must-Support: 14 elements
Prohibited: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ IHE Radiology Technical Committee. Package ihe.rad.idr#0.0.1-current based on FHIR 5.0.0. Generated 2024-06-25
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