HL7 Europe Laboratory Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.2.0-ci built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/laboratory/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.eu/fhir/laboratory/StructureDefinition/Composition-eu-lab | Version: 0.2.0-ci | |||
Standards status: Trial-use | Maturity Level: 2 | Computable Name: CompositionLabReportEu | ||
Copyright/Legal: Used by permission of HL7 Europe, all rights reserved Creative Commons License |
Clinical document used to represent a Laboratory Report for the scope of the HL7 Europe project.
Based on order
This version of the guide uses the HL7 Europe basedOn-order-or-requisition extension to link this Composition to the to the order or requisition.
Implementers are invited to provide their feedback about the possible adoption of the standard extension event-basedOn for referring the order fulfilled.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Clinical Document
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |
text | 0..1 | Narrative | Narrative text | |
Slices for extension | Content/Rules for all slices | |||
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
Slices for value[x] | 0..1 | Identifier, Reference(ServiceRequest) | Value of extension Slice: Unordered, Open by type:$this | |
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |
reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
identifier | 0..1 | Identifier | Report identifier | |
status | 1..1 | code | Status of the Report | |
type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
Slices for category | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this | |
category:studyType | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | |
category:specialty | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | |
subject | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | |
encounter | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | |
author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | |
title | 1..1 | string | Laboratory Report | |
attester | 0..* | BackboneElement | Attests the report accuracy | |
mode | 1..1 | code | The type of attestation | |
time | 0..1 | dateTime | When the report was attested by the party | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
event | 0..* | BackboneElement | The laboratory service(s) being documented | |
code | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented | |
period | 0..1 | Period | Period of time covered by the documentation | |
detail | 0..* | Reference(Resource) | The laboratory service(s) being documented | |
Slices for section | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | |
section:All Slices | Content/Rules for all slices | |||
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | |
section:lab-no-subsections | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
section | 0..0 | |||
section:lab-subsections | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | 0..0 | |||
entry | 0..0 | |||
section | 1..* | BackboneElement | Nested Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
section | 0..0 | |||
section:annotations | 0..* | BackboneElement | Annotation comment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..0 | |||
section | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab from this IG | |
Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab from this IG | |
Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | 0..1 | Narrative | Narrative text | |
Slices for extension | Content/Rules for all slices | |||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |
Slices for value[x] | 0..1 | Value of extension Slice: Unordered, Open by type:$this | ||
valueIdentifier | Identifier | |||
valueReference | Reference(ServiceRequest) | |||
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |
reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..1 | Identifier | Report identifier |
status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) |
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) |
subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about |
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report |
title | Σ | 1..1 | string | Laboratory Report |
attester | 0..* | BackboneElement | Attests the report accuracy | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
time | 0..1 | dateTime | When the report was attested by the party | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
period | Σ | 0..1 | Period | Period of time covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented |
Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
section | C | 1..* | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
section:annotations | C | 0..* | BackboneElement | Annotation comment cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab from this IG | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:annotations.code | example | Pattern: LOINC Code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | 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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |||||
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.
| |||||
text | 0..1 | Narrative | Narrative text | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
Slices for value[x] | 0..1 | Value of extension Slice: Unordered, Open by type:$this | ||||||
valueIdentifier | Identifier | |||||||
valueReference | Reference(ServiceRequest) | |||||||
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |||||
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Report identifier | ||||
status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |||||
Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | ||||
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | ||||
subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | ||||
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
date | Σ | 1..1 | dateTime | Composition editing time | ||||
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | ||||
title | Σ | 1..1 | string | Laboratory Report | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests the report accuracy | |||||
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 | ||||
mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the report was attested by the party | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
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 | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented | ||||
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 | ||||
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | Σ | 0..1 | Period | Period of time covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented | ||||
Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
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 | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 1..* | BackboneElement | Nested Section | ||||
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 | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:annotations | C | 0..* | BackboneElement | Annotation comment cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.extension:diagnosticReport-reference.value[x].type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab from this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | ||||
Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab from this IG | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | ||||
Composition.section:lab-no-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:lab-no-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:lab-no-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | ||||
Composition.section:lab-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:lab-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:lab-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | ||||
Composition.section:lab-subsections.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:lab-subsections.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:lab-subsections.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:annotations.code | example | Pattern: LOINC Code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:annotations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:annotations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:annotations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | 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() |
This structure is derived from Clinical Document
Summary
Mandatory: 4 elements(8 nested mandatory elements)
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from Clinical Document
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |
text | 0..1 | Narrative | Narrative text | |
Slices for extension | Content/Rules for all slices | |||
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
Slices for value[x] | 0..1 | Identifier, Reference(ServiceRequest) | Value of extension Slice: Unordered, Open by type:$this | |
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |
reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
identifier | 0..1 | Identifier | Report identifier | |
status | 1..1 | code | Status of the Report | |
type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
Slices for category | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this | |
category:studyType | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | |
category:specialty | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | |
subject | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | |
encounter | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | |
author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | |
title | 1..1 | string | Laboratory Report | |
attester | 0..* | BackboneElement | Attests the report accuracy | |
mode | 1..1 | code | The type of attestation | |
time | 0..1 | dateTime | When the report was attested by the party | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
event | 0..* | BackboneElement | The laboratory service(s) being documented | |
code | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented | |
period | 0..1 | Period | Period of time covered by the documentation | |
detail | 0..* | Reference(Resource) | The laboratory service(s) being documented | |
Slices for section | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | |
section:All Slices | Content/Rules for all slices | |||
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | |
section:lab-no-subsections | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
section | 0..0 | |||
section:lab-subsections | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | 0..0 | |||
entry | 0..0 | |||
section | 1..* | BackboneElement | Nested Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
section | 0..0 | |||
section:annotations | 0..* | BackboneElement | Annotation comment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..0 | |||
section | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab from this IG | |
Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab from this IG | |
Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | 0..1 | Narrative | Narrative text | |
Slices for extension | Content/Rules for all slices | |||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |
Slices for value[x] | 0..1 | Value of extension Slice: Unordered, Open by type:$this | ||
valueIdentifier | Identifier | |||
valueReference | Reference(ServiceRequest) | |||
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |
reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..1 | Identifier | Report identifier |
status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) |
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) |
subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about |
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report |
title | Σ | 1..1 | string | Laboratory Report |
attester | 0..* | BackboneElement | Attests the report accuracy | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
time | 0..1 | dateTime | When the report was attested by the party | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
period | Σ | 0..1 | Period | Period of time covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented |
Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
section | C | 1..* | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
section:annotations | C | 0..* | BackboneElement | Annotation comment cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab from this IG | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab from this IG | |
Composition.section:annotations.code | example | Pattern: LOINC Code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | 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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Clinical Document | Laboratory Report composition | |||||
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.
| |||||
text | 0..1 | Narrative | Narrative text | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
basedOn-order-or-requisition | 0..* | (Complex) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
Slices for value[x] | 0..1 | Value of extension Slice: Unordered, Open by type:$this | ||||||
valueIdentifier | Identifier | |||||||
valueReference | Reference(ServiceRequest) | |||||||
value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |||||
diagnosticReport-reference | 0..1 | (Complex) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Id |