Repositorio de Reportes de Biopsias Oncológicas
0.1.1-draft - STU1

Repositorio de Reportes de Biopsias Oncológicas, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/R2BO/ and changes regularly. See the Directory of published versions

## Resource Profile: Perfil del Reporte de Anatomía Patológica ( Experimental )

Official URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia | Version: 0.1.1-draft
Standards status: Draft | Maturity Level: 1 | Computable Name: R2BOInformeBiopsia

Reporte de anatomía patológica

Usages:

- Use this Profile: Perfil de Bundle para Generar Informe
- Refer to this Profile: Extensión De Referencia al Reporte
- Examples for this Profile: DiagnosticReport/r2bo-informe-biopsia-ex
- CapabilityStatements using this Profile: CapabilityStatement del Cliente Analista del Repositorio de Biopsia del Ministerio de Salud, CapabilityStatement Cliente de Origen de Informes del Repositorio de Biopsia del Ministerio de Salud, CapabilityStatement Consumidor del Repositorio de Biopsia del Ministerio de Salud and CapabilityStatement Servidor del Repositorio de Biopsia del Ministerio de Salud

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | ?!S Σ | 1..1 | code | Estado del Informe de Anatomía Patológica Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final
category | S Σ | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S Σ | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
issued | S Σ | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S Σ | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
Slices for extension |  | 0..* | Extension | Grado de diferenciación tumoral Slice: Unordered, Open by value:url
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
contentType | S Σ | 0..1 | code | Tipo de Contenido Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG
DiagnosticReport.presentedForm.​contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

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()`
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-1
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
identifier | S | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | S | 1..1 | code | Estado del Informe de Anatomía Patológica Required Pattern: final
category | S | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
code | S | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
issued | S | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
extension |  | 0..* | Extension | Grado de diferenciación tumoral
Slices for extension |  |  |  | Content/Rules for all slices
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
contentType | S | 0..1 | code | Tipo de Contenido
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category | Base | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-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: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | ?!S Σ | 1..1 | code | Estado del Informe de Anatomía Patológica Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final
category | S Σ | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S Σ | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
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 | S Σ | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S Σ | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
Slices for extension |  | 0..* | Extension | Grado de diferenciación tumoral Slice: Unordered, Open by value:url
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | S Σ | 0..1 | code | Tipo de Contenido Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
url | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
Documentation for this format

#### Terminology Bindings

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 | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG
DiagnosticReport.presentedForm.​contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DiagnosticReport.presentedForm.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.

#### Constraints

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()`
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

This structure is derived from DiagnosticReport

Summary

Mandatory: 10 elements(2 nested mandatory elements)
Must-Support: 21 elements

Structures

This structure refers to these other structures:

- Perfil de Solicitud de Informe de Anatomía Patológica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-solicitud-informe-apa)
- MINSAL Paciente (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPaciente)
- Perfil de Rol Profesional (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-rol-profesional-minsal)
- Prestador Profesional (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPrestadorProfesional)
- Prestador Institucional (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPrestadorOrganizacional)
- Perfil de Muestra (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-muestra-biopsia)
- Perfil de Origen de Todos Los Resultados (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-resultados-reporte-biopsia)
- Perfil de Observación Microscópica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-microscopica)
- Perfil de Observación Macroscópica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica)
- Perfil de Grupo Estadificación TNM (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-estadificacion-tnm)
- Perfil de Observación Infiltración Perineural (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-infiltracion-perineural)
- Perfil de Observación Ganglios Linfáticos (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-ganglios-linfaticos)
- Perfil de Observación Infiltración Peritumoral (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-infiltracion-peritumoral)
- Perfil de Observación Invasión Linfatica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-invasion-linfatica)
- Perfil de Observación Invasión Vascular (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-invasion-vascular)
- Perfil de Observación Margen Quirúrgico (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-margen-quirurgico)
- Perfil de Observación Multicentricidad (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-multicentricidad)
- Perfil de Observación Focalidad (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-focalidad)
- Perfil de Observación Evaluación Post Neoadyuvancia (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-post-tratamiento-neoadjuvancia)
- Perfil de Observación Porcentaje Necrosis (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-porcentaje-necrosis)
- Perfil de Observacion Tejido No Tumoral Adyacente (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-tejido-no-tumor-adyacente)
- Perfil de Tamaño del Tumor (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-tamano-tumor)

Extensions

This structure refers to these extensions:

- https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
- https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.result
- The element 1 is sliced based on the value of DiagnosticReport.conclusionCode

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | ?!S Σ | 1..1 | code | Estado del Informe de Anatomía Patológica Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final
category | S Σ | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S Σ | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
issued | S Σ | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S Σ | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
Slices for extension |  | 0..* | Extension | Grado de diferenciación tumoral Slice: Unordered, Open by value:url
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
contentType | S Σ | 0..1 | code | Tipo de Contenido Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG
DiagnosticReport.presentedForm.​contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

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()`
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

Differential View

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-1
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
identifier | S | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | S | 1..1 | code | Estado del Informe de Anatomía Patológica Required Pattern: final
category | S | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
code | S | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
issued | S | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
extension |  | 0..* | Extension | Grado de diferenciación tumoral
Slices for extension |  |  |  | Content/Rules for all slices
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
contentType | S | 0..1 | code | Tipo de Contenido
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category | Base | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: r2bo-diag-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: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:composition | S | 0..1 | Reference(Perfil del Documento de Biopsía) | Refernecia al composition del documento URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | Identificador del Informe de Anatomía Patológica
basedOn | S | 1..1 | Reference(Perfil de Solicitud de Informe de Anatomía Patológica) | Solicitud de Biopsia
status | ?!S Σ | 1..1 | code | Estado del Informe de Anatomía Patológica Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: final
category | S Σ | 1..1 | CodeableConcept | Categoría del Informe de Anatomía Patológica Binding: Set de Valores de la Categoría Reportes de Biopsia (extensible) 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/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Código del Informe de Anatomía Patológica Binding: Set de Valores de los Reportes de Biopsia (extensible)
subject | S Σ | 1..1 | Reference(MINSAL Paciente) | Paciente del Informe de Anatomía Patológica
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 | S Σ | 1..1 | instant | Fecha de Emisión del Informe de Anatomía Patológica
performer | S Σ | 1..1 | Reference(Perfil de Rol Profesional | Prestador Profesional | Prestador Institucional) | Anatomopatólogo que realiza el Informe
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen | S | 1..* | Reference(Perfil de Muestra) | Muestra de Biopsia
Slices for result |  | 1..* | Reference(Perfil de Origen de Todos Los Resultados) | Resultados del Informe de Anatomía Patológica Slice: Unordered, Open by profile:resolve()
result:Microscopia | S | 1..1 | Reference(Perfil de Observación Microscópica) | Resultados de Microscopía
result:Macroscopia | S | 0..1 | Reference(Perfil de Observación Macroscópica) | Resultados de Macroscopía
result:TNM | S | 0..1 | Reference(Perfil de Grupo Estadificación TNM) | Estadificación patológica TNM
result:Resultados |  | 0..* | Reference(Perfil de Observación Infiltración Perineural | Perfil de Observación Ganglios Linfáticos | Perfil de Observación Infiltración Peritumoral | Perfil de Observación Invasión Linfatica | Perfil de Observación Invasión Vascular | Perfil de Observación Margen Quirúrgico | Perfil de Observación Multicentricidad | Perfil de Observación Focalidad | Perfil de Observación Evaluación Post Neoadyuvancia | Perfil de Observación Porcentaje Necrosis | Perfil de Observacion Tejido No Tumoral Adyacente | Perfil de Tamaño del Tumor) | Otros posibles resultados
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion | S | 1..1 | string | Conclusión narrativa del informe de anatomía patológica
Slices for conclusionCode | S | 0..2 | CodeableConcept | Conclusión codificada del informe de anatomía patológica Slice: Unordered, Open by value:id Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
conclusionCode:Morfologico | S | 0..1 | CodeableConcept | Conclusión Morfológica Binding: Set de Valores Morfología (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Morfologico
Slices for extension |  | 0..* | Extension | Grado de diferenciación tumoral Slice: Unordered, Open by value:url
extension:gradoDiferenciacion | S | 0..1 | CodeableConcept | Extensión del Grado de Diferenciación URL: https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion Binding: Set de Valores Para Grado de Diferenciación (required): Grado de diferenciación tumoral según clasificación de la OMS
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
conclusionCode:Topografico | S | 0..1 | CodeableConcept | Conclusión Topográfica Binding: Set de Valores para Topografía (extensible)
id |  | 1..1 | string | Unique id for inter-element referencing Required Pattern: Topografico
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
presentedForm | S | 0..* | Attachment | Representación del Informe de Anatomía Patológica
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | S Σ | 0..1 | code | Tipo de Contenido Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | S | 0..1 | base64Binary | Informe de Anatomía Patológica en base64
url | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
Documentation for this format

#### Terminology Bindings

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 | extensible | Set de Valores de la Categoría Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.code | Base | extensible | Set de Valores de los Reportes de Biopsia | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.
DiagnosticReport.conclusionCode:Morfologico | Base | extensible | Set de Valores Morfología | 📦0.1.1-draft | This IG
DiagnosticReport.conclusionCode:Topografico | Base | extensible | Set de Valores para Topografía | 📦0.1.1-draft | This IG
DiagnosticReport.presentedForm.​contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DiagnosticReport.presentedForm.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.

#### Constraints

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()`
r2bo-diag-1 | error | DiagnosticReport | Si el reporte es de categoría patológico la observación macroscópica debe existir | `(category.coding.where(code = 'PAT').exists()) implies (result.resolve().where(conformsTo('https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica')).exists())`

This structure is derived from DiagnosticReport

Summary

Mandatory: 10 elements(2 nested mandatory elements)
Must-Support: 21 elements

Structures

This structure refers to these other structures:

- Perfil de Solicitud de Informe de Anatomía Patológica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-solicitud-informe-apa)
- MINSAL Paciente (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPaciente)
- Perfil de Rol Profesional (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-rol-profesional-minsal)
- Prestador Profesional (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPrestadorProfesional)
- Prestador Institucional (https://interoperabilidad.minsal.cl/fhir/ig/nid/StructureDefinition/MINSALPrestadorOrganizacional)
- Perfil de Muestra (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-muestra-biopsia)
- Perfil de Origen de Todos Los Resultados (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-resultados-reporte-biopsia)
- Perfil de Observación Microscópica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-microscopica)
- Perfil de Observación Macroscópica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-macroscopica)
- Perfil de Grupo Estadificación TNM (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-estadificacion-tnm)
- Perfil de Observación Infiltración Perineural (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-infiltracion-perineural)
- Perfil de Observación Ganglios Linfáticos (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-ganglios-linfaticos)
- Perfil de Observación Infiltración Peritumoral (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-infiltracion-peritumoral)
- Perfil de Observación Invasión Linfatica (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-invasion-linfatica)
- Perfil de Observación Invasión Vascular (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-invasion-vascular)
- Perfil de Observación Margen Quirúrgico (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-margen-quirurgico)
- Perfil de Observación Multicentricidad (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-multicentricidad)
- Perfil de Observación Focalidad (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-focalidad)
- Perfil de Observación Evaluación Post Neoadyuvancia (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-post-tratamiento-neoadjuvancia)
- Perfil de Observación Porcentaje Necrosis (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-porcentaje-necrosis)
- Perfil de Observacion Tejido No Tumoral Adyacente (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-observacion-tejido-no-tumor-adyacente)
- Perfil de Tamaño del Tumor (https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-tamano-tumor)

Extensions

This structure refers to these extensions:

- https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition
- https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-grado-diferenciacion

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.result
- The element 1 is sliced based on the value of DiagnosticReport.conclusionCode

Maturity: 1

Other representations of profile: CSV, Excel, Schematron