HL7 Europe Imaging Study Report
0.1.0 - ci-build 150

HL7 Europe Imaging Study Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/imaging/ and changes regularly. See the Directory of published versions

Resource Profile: Imaging Diagnostic Report

Official URL: http://hl7.eu/fhir/imaging/StructureDefinition/im-diagnostic-report Version: 0.1.0
Standards status: Draft Maturity Level: 1 Computable Name: ImDiagnosticReport

Copyright/Legal: Used by permission of HL7 Europe, all rights reserved Creative Commons License

Diagnostic Report profile for Imaging Reports. This document represents the report of an imaging study. It is the anchor resource that refers to all structured data as well as the Composition resource that contains the narrative text of the report.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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`
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: 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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... meta Σ 0..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... security SΣ 0..* Coding Security Labels applied to this resource
Binding: AllSecurityLabels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... language S 0..1 code Language of the resource content
Binding: AllLanguages (required): IETF language tag for a human language

Additional BindingsPurpose
CommonLanguages Starter Set

ele-1: All FHIR elements must have a @value or children
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... extension:artifactVersion 0..1 string Business version of the artifact
URL: http://hl7.org/fhir/StructureDefinition/artifact-version
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier SOΣ 0..1 ImAccessionNumberIdentifier Report identifier
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... Slices for basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... basedOn:imorderaccession S 0..1 Reference(Imaging Order) What was requested
ele-1: All FHIR elements must have a @value or children
... status ?!Σ 1..1 code Status of the Report
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


ele-1: All FHIR elements must have a @value or children
... code SΣ 1..1 CodeableConcept Type of Imaging Diagnostic Report
Binding: Imaging Report Types (preferred)
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(Imaging Patient) The subject of the report - usually, but not always, the patient
ele-1: All FHIR elements must have a @value or children
... issued SΣ 1..1 instant DateTime that this diagnostic report is published.
ele-1: All FHIR elements must have a @value or children
... Slices for resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
Slice: Unordered, Open by profile:resolve()
ele-1: All FHIR elements must have a @value or children
.... resultsInterpreter:author SOΣ 0..* Reference(Report Author) Primary result interpreter
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... result SOC 0..* Reference(Finding) Observations
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... study SO 0..1 Reference(ImagingStudy) Reference to full details of an analysis associated with the diagnostic report
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... Slices for supportingInfo S 0..* BackboneElement Additional information supporting the diagnostic report
Slice: Unordered, Open by value:""reference""
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type 1..1 CodeableConcept Supporting information role code
Binding: DiagnosticReport supportInfo codes (extensible)
ele-1: All FHIR elements must have a @value or children
..... reference 1..1 Reference(Procedure | Observation | DiagnosticReport | Citation) Supporting information reference
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:procedure SO 0..* BackboneElement Additional information supporting the diagnostic report
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type 1..1 CodeableConcept Supporting information role code
Binding: DiagnosticReport supportInfo codes (extensible)
ele-1: All FHIR elements must have a @value or children
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://hl7.eu/fhir/imaging/CodeSystem/codesystem-diagnostic-report-support-info
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: imaging-procedure
..... reference 1..1 Reference(Imaging Procedure) Supporting information reference
ele-1: All FHIR elements must have a @value or children
... composition SC 1..1 Reference(Imaging Composition) Imaging Diagnostic Report
ele-1: All FHIR elements must have a @value or children
... conclusion SO 0..1 markdown Clinical conclusion (interpretation) of test results
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... conclusionCode SO 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings


ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer
... presentedForm SO 0..* Attachment Printed versions of the report.
ele-1: All FHIR elements must have a @value or children
ObligationsActor
SHALL:populate-if-known IM Producer

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.meta.securityextensibleAllSecurityLabels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DiagnosticReport.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status|5.0.0
from the FHIR Standard
DiagnosticReport.codepreferredImagingReportTypesEuVS
http://hl7.eu/fhir/imaging/ValueSet/im-reportType-eu-lab
from this IG
DiagnosticReport.supportingInfo.typeextensibleDiagnosticReportSupportingInfoVCodes (a valid code from Diagnostic Report Support Info Code System)
http://hl7.eu/fhir/imaging/ValueSet/valueset-diagnosticreport-report-support-info
from this IG
DiagnosticReport.supportingInfo:procedure.typeextensiblePattern: imaging-procedure
http://hl7.eu/fhir/imaging/ValueSet/valueset-diagnosticreport-report-support-info
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dgr-1errorDiagnosticReportWhen a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember`
: composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron