Integrated Reporting Applications, published by IHE Radiology Technical Committee. This is not an authorized publication; it is the continuous build for version 0.1.1). This version is based on the current content of https://github.com/IHE/RAD.RTC-IMR/ and changes regularly. See the Directory of published versions

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Resource Profile: DiagnosticReport Context

IHE IRA DiagnosticReport-open report context

Usage:

• Examples for this Resource Profile: DiagnosticReport/example-DiagnosticReportContext

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
status		1..1	code	registered | partial | preliminary | final + Required Pattern: unknown
subject		0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic report
Documentation for this format

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
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
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown
code	Σ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject	Σ	0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic report
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
DiagnosticReport.status	required	Pattern: unknown
DiagnosticReport.code	preferred	LOINCDiagnosticReportCodes (a valid code from LOINC)

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
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		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	?!Σ	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	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown
category	Σ	0..*	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	Σ	0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result	C	0..*	Reference(Observation)	Observations
note		0..*	Annotation	Comments about the diagnostic report
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic 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
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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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	C	0..1	Reference(Composition)	Reference to a Composition resource for the DiagnosticReport structure
conclusion		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

Terminology Bindings

Path	Conformance	ValueSet / Code
DiagnosticReport.language	required	AllLanguages
DiagnosticReport.status	required	Pattern: unknown
DiagnosticReport.category	example	DiagnosticServiceSectionCodes
DiagnosticReport.code	preferred	LOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.supportingInfo.type	example	Hl7VSVSObservationType
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings

This structure is derived from DiagnosticReport

Summary

Differential View

This structure is derived from DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
status		1..1	code	registered | partial | preliminary | final + Required Pattern: unknown
subject		0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic report
Documentation for this format

Key Elements 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
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
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown
code	Σ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject	Σ	0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic report
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
DiagnosticReport.status	required	Pattern: unknown
DiagnosticReport.code	preferred	LOINCDiagnosticReportCodes (a valid code from LOINC)

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
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		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	?!Σ	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	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown
category	Σ	0..*	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	Σ	0..1	Reference(Patient)	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result	C	0..*	Reference(Observation)	Observations
note		0..*	Annotation	Comments about the diagnostic report
study		0..*	Reference(ImagingStudy)	Reference to full details of an analysis associated with the diagnostic 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
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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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	C	0..1	Reference(Composition)	Reference to a Composition resource for the DiagnosticReport structure
conclusion		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

Terminology Bindings

Path	Conformance	ValueSet / Code
DiagnosticReport.language	required	AllLanguages
DiagnosticReport.status	required	Pattern: unknown
DiagnosticReport.category	example	DiagnosticServiceSectionCodes
DiagnosticReport.code	preferred	LOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.supportingInfo.type	example	Hl7VSVSObservationType
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings

This structure is derived from DiagnosticReport

Summary

Other representations of profile: CSV, Excel, Schematron