QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.0)

QI-Core Implementation Guide, Clinical Quality Improvement WG - CI build for vesion 4.0.0). This version is based on the current content of https://github.com/cqframework/qi-core/ and changes regularly. See the Directory of published versions

D.4.1 StructureDefinition-qicore-diagnosticreport-lab

Introduction:

See the patterns page for implementation and usage patterns.

Examples:

Blood Panel Example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-lab

Profile of DiagnosticReport for laboratory results for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

This profile builds on USCoreDiagnosticReportProfileLaboratoryReporting.

This profile was published on Wed Aug 22 00:00:00 UTC 2018 as a draft by Health Level Seven, Inc. - CQI WG.

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... diagnosticReport-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... locationPerformed-valueReference 1..1Reference(QICoreLocation)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ(Slice Definition)Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example)
.... lab SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example)

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptUS Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible)
... subject Σ1..1Reference(QICorePatient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(QICoreEncounter)Health care event when test ordered
... effective[x] Σ1..1Specimen Collection Datetime or Period
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ1..1instantDateTime this version was made
... performer Σ0..*Reference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(QICoreSpecimen)Specimens this report is based on
... result SI0..*Reference(QICoreObservation)Observations
... imagingStudy S0..*Reference(QICoreImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (preferred)
... presentedForm SI0..*AttachmentEntire report as issued
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... diagnosticReport-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... locationPerformed-valueReference 1..1Reference(QICoreLocation)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ(Slice Definition)Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example)
.... lab SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example)

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptUS Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible)
... subject Σ1..1Reference(QICorePatient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(QICoreEncounter)Health care event when test ordered
... effective[x] Σ1..1Specimen Collection Datetime or Period
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ1..1instantDateTime this version was made
... performer Σ0..*Reference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(QICoreSpecimen)Specimens this report is based on
... result SI0..*Reference(QICoreObservation)Observations
... imagingStudy S0..*Reference(QICoreImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (preferred)
... presentedForm SI0..*AttachmentEntire report as issued
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present.

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:labexamplePattern: LAB
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
DiagnosticReport.conclusionCodepreferredSNOMEDCTClinicalFindings

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4DiagnosticReportIf 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-3DiagnosticReportIf 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-6DiagnosticReportA resource should have narrative for robust management
: text.div.exists()
dom-5DiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
us-core-7DiagnosticReportDiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present.
: result.exists() or presentedForm.exists()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-7DiagnosticReport.resultDiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present.
: result.exists() or presentedForm.exists()
ele-1DiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
us-core-7DiagnosticReport.presentedFormDiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present.
: result.exists() or presentedForm.exists()