HL7 FHIR Implementation Guide Laboratory Report
0.2.0 - trial-use

HL7 FHIR Implementation Guide Laboratory Report, published by HL7 Italia. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-it/lab-report/ and changes regularly. See the Directory of published versions

## Resource Profile: DiagnosticReportRefertoLabIt - Detailed Descriptions

Page standards status: Trial-use | Maturity Level: 1

Definitions for the diagnosticreport-it-lab resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. DiagnosticReport
Definition | Laboratory Report DiagnosticReport The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
Short | DiagnosticReport Referto di LaboratorioA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Comments | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Report, Test, Result, Results, Labs, Laboratory
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) 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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. DiagnosticReport.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. DiagnosticReport.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `DiagnosticReport.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. DiagnosticReport.extension:DiagnosticReportCompositionR5
Slice Name | DiagnosticReportCompositionR5
Definition | An Extension
Short | Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Extension Definition for DiagnosticReport.composition for Version 5.0) (Extension Type: Reference(Composition))
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. DiagnosticReport.extension:DiagnosticReportCompositionR5.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..0*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `DiagnosticReport.extension.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
10. DiagnosticReport.extension:DiagnosticReportCompositionR5.url
Definition | Source of the definition for the extension code - a logical name or a URL.
Short | identifies the meaning of the extension
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Control | 1..1
Type | uri
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
Fixed Value | `http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition`
12. DiagnosticReport.extension:DiagnosticReportCompositionR5.value[x]
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Short | Reference a Composition.Value of extension
Control | 10..1
Type | Reference(Composition - Lab Report), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. DiagnosticReport.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. DiagnosticReport.identifier
Definition | Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions Identifiers assigned to this report by the performer or other systems.
Short | Identificativo indipendente dalla versione.Business identifier for report
Comments | Composition.identifier DEVE essere uguale ad uno dei DiagnosticReport.identifier, se ne esiste almeno uno. Usually assigned by the Information System of the diagnostic service provider (filler id).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..1*
Type | Identifier
Is Modifier | false
Summary | true
Requirements | Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
Alternate Names | ReportID, Filler ID, Placer ID
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. DiagnosticReport.basedOn
Definition | Details concerning a service requested.
Short | Reference a una o più prestazioni richieste associate al referto.What was requested
Comments | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
Control | 0..*
Type | Reference(ServiceRequest - Lab Report, CarePlan, ImmunizationRecommendation, MedicationRequest, NutritionOrder, ServiceRequest)
Is Modifier | false
Summary | false
Requirements | This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Alternate Names | Request
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. DiagnosticReport.status
Definition | The status of the diagnostic report.
Short | Stato del Refertoregistered | partial | preliminary | final +
Comments | DiagnosticReport.status e Composition.status devono essere coerenti, vedi http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus per il mapping.
Control | 1..1
Binding | The codes SHALL be taken from DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/diagnostic-report-status` )
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. DiagnosticReport.category
Definition | Specifies the Report Category: usually Laboratory A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Short | Report CategoryService category
Comments | DiagnosticReport.category e Composition.category devono essere allineati. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
Control | 0..*
Binding | For example codes, see DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections|4.0.1 (example to `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` ) Codes for diagnostic service sections.
Type | CodeableConcept(Codeable Concept (IPS))
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `DiagnosticReport.category`. The slices areUnordered and Open, and can be differentiated using the following discriminators: pattern @ $this
24. DiagnosticReport.category:studyType
Slice Name | studyType
Definition | Laboratory services, i.e., results of tests performed, could be characterized using typology of services, commonly called study types. Study type could be seen as an attribute or grouping mechanism that assigns a common clinical sense to certain types of laboratory test results., e.g., Hemoglobin, Platelet count, etc. belongs to 'Hematology study'. A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Short | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)Service category
Comments | In comparison to the laboratory specialty which is an attribute of laboratory, study type is a categorization of laboratory service. It needs to be mentioned that classification of test to study types in not standardized. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
Control | 0..*
Binding | The codes SHALL be taken from For example codes, see Laboratory Study Types http://hl7.org/fhir/ValueSet/diagnostic-service-sections|4.0.1 (required to `http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. DiagnosticReport.category:specialty
Slice Name | specialty
Definition | Laboratory specialty is an attribute of any laboratory setting representing professional qualification of the laboratory to execute certain kind of laboratory tests. A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Short | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)Service category
Comments | Specialty could be used as parameter for searching/querying of laboratory test results. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
Control | 0..*
Binding | The codes SHALL be taken from For example codes, see Laboratory Specialty http://hl7.org/fhir/ValueSet/diagnostic-service-sections|4.0.1 (required to `http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. DiagnosticReport.code
Definition | Specifica che il documento è un Referto di Laboratorio A code or name that describes this diagnostic report.
Short | Referto di LaboratorioName/Code for this diagnostic report
Comments | DiagnosticReport.code e Composition.type devono essere allineati.
Control | 1..1 This element is affected by the following invariants: ele-1
Binding | The codes SHOULD be taken from Laboratory Report Types http://hl7.org/fhir/ValueSet/report-codes|4.0.1 (preferred to `http://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab` )
Type | CodeableConcept(Codeable Concept (IPS))
Is Modifier | false
Alternate Names | Type
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11502-2", "display" : "Laboratory report" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. DiagnosticReport.code.coding
Definition | A reference to a code defined by a terminology system.
Short | Codice definito da un sistema terminologico.Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Coding(Coding with translations)
Is Modifier | false
Must Support | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. DiagnosticReport.code.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. DiagnosticReport.subject
Definition | Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.
Short | Who and/or what this report is aboutThe subject of the report - usually, but not always, the patient
Comments | DiagnosticReport e Composition devono avere lo stesso subject
Control | 10..1
Type | Reference(Patient - Lab Report, Patient, Group, Device, Location)
Is Modifier | false
Summary | true
Requirements | SHALL know the subject context.
Alternate Names | Patient
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. DiagnosticReport.encounter
Definition | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
Short | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione).Health care event when test ordered
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport e Composition devono referenziare lo stesso encounter. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Control | 0..1
Type | Reference(Encounter - Lab Report, Encounter)
Is Modifier | false
Summary | true
Requirements | Links the request to the Encounter context.
Alternate Names | Context
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. DiagnosticReport.performer
Definition | Organizzazione o Persona che è responsabile del report; non è necessariamente l'autore dei dati atomici o l'entità che ha interpretato i risultati. The diagnostic service that is responsible for issuing the report.
Short | Persona o Organizzazione che partecipa all'evento clinico descritto.Responsible Diagnostic Service
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
Control | 0..*
Type | Reference(Practitioner - Lab Report, PractitionerRole - Lab Report, Organization - Lab Report, CareTeam, Practitioner, PractitionerRole, Organization, CareTeam)
Is Modifier | false
Summary | true
Requirements | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Alternate Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. DiagnosticReport.resultsInterpreter
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in. The practitioner or organization that is responsible for the report's conclusions and interpretations.
Short | Chi e/o cosa è l'autore del referto di laboratorio.Primary result interpreter
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore. Might not be the same entity that takes responsibility for the clinical report.
Control | 0..*
Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam, Practitioner, PractitionerRole, Organization, CareTeam)
Is Modifier | false
Summary | true
Requirements | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Alternate Names | Analyzed by, Reported by
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. DiagnosticReport.specimen
Definition | Details about the specimens on which this diagnostic report is based.
Short | Reference ai campioni su cui si basa la DiagnosticReport.Specimens this report is based on
Comments | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Control | 0..*
Type | Reference(Specimen - Lab Report, Specimen)
Is Modifier | false
Summary | false
Requirements | Need to be able to report information about the collected specimens on which the report is based.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. DiagnosticReport.result
Definition | Observations that are part of this diagnostic report.
Short | Osservazioni cliniche.Observations
Comments | Observations can contain observations.
Control | 0..*
Type | Reference(Observation - Lab Report, Observation)
Is Modifier | false
Summary | false
Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. DiagnosticReport.imagingStudy
Definition | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
Short | Reference to full details of imaging associated with the diagnostic report
Comments | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Control | 0..0*
Type | Reference(ImagingStudy, ImagingStudy)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. DiagnosticReport.media
Definition | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Short | Contenuto multimediale associate al DiagnosticReport.Key images associated with this report
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | Many diagnostic services include images in the report as part of their service.
Alternate Names | DICOM, Slides, Scans
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. DiagnosticReport.media.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. DiagnosticReport.media.comment
Definition | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.
Short | Commento sull'immagine.Comment about the image (e.g. explanation)
Comments | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The provider of the report should make a comment about each image included in the report.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. DiagnosticReport.media.link
Definition | Reference to the image source.
Short | Riferimento al contenuto multimediale.Reference to the image source
Control | 1..1
Type | Reference(Media - Lab Report, Media)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. DiagnosticReport.presentedForm
Definition | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Short | Rappresentazione testuale del Referto di Laboratorio così come emesso.Entire report as issued
Comments | "application/pdf" is recommended as the most reliable and interoperable in this context.
Control | 0..*
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. DiagnosticReport
Short | DiagnosticReport Referto di Laboratorio
2. DiagnosticReport.extension:DiagnosticReportCompositionR5
Slice Name | DiagnosticReportCompositionR5
Short | Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
4. DiagnosticReport.extension:DiagnosticReportCompositionR5.value[x]
Short | Reference a Composition.
Type | Reference(Composition - Lab Report)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
6. DiagnosticReport.identifier
Short | Identificativo indipendente dalla versione.
Comments | Composition.identifier DEVE essere uguale ad uno dei DiagnosticReport.identifier, se ne esiste almeno uno.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
8. DiagnosticReport.basedOn
Short | Reference a una o più prestazioni richieste associate al referto.
Type | Reference(ServiceRequest - Lab Report)
10. DiagnosticReport.status
Short | Stato del Referto
Comments | DiagnosticReport.status e Composition.status devono essere coerenti, vedi http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus per il mapping.
Binding | The codes SHALL be taken from DiagnosticReportStatus (required to `http://hl7.org/fhir/ValueSet/diagnostic-report-status` )
12. DiagnosticReport.category
Definition | Specifies the Report Category: usually Laboratory
Comments | DiagnosticReport.category e Composition.category devono essere allineati.
14. DiagnosticReport.code
Definition | Specifica che il documento è un Referto di Laboratorio
Short | Referto di Laboratorio
Comments | DiagnosticReport.code e Composition.type devono essere allineati.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11502-2", "display" : "Laboratory report" }] }`
16. DiagnosticReport.code.coding
Short | Codice definito da un sistema terminologico.
18. DiagnosticReport.subject
Comments | DiagnosticReport e Composition devono avere lo stesso subject
Type | Reference(Patient - Lab Report)
20. DiagnosticReport.encounter
Definition | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione).
Short | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione).
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport e Composition devono referenziare lo stesso encounter.
Type | Reference(Encounter - Lab Report)
22. DiagnosticReport.performer
Definition | Organizzazione o Persona che è responsabile del report; non è necessariamente l'autore dei dati atomici o l'entità che ha interpretato i risultati.
Short | Persona o Organizzazione che partecipa all'evento clinico descritto.
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore.
Type | Reference(Practitioner - Lab Report, PractitionerRole - Lab Report, Organization - Lab Report, CareTeam)
24. DiagnosticReport.resultsInterpreter
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in.
Short | Chi e/o cosa è l'autore del referto di laboratorio.
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore.
26. DiagnosticReport.specimen
Short | Reference ai campioni su cui si basa la DiagnosticReport.
Type | Reference(Specimen - Lab Report)
28. DiagnosticReport.result
Short | Osservazioni cliniche.
Type | Reference(Observation - Lab Report)
30. DiagnosticReport.media
Short | Contenuto multimediale associate al DiagnosticReport.
32. DiagnosticReport.media.comment
Short | Commento sull'immagine.
34. DiagnosticReport.media.link
Short | Riferimento al contenuto multimediale.
Type | Reference(Media - Lab Report)
36. DiagnosticReport.presentedForm
Short | Rappresentazione testuale del Referto di Laboratorio così come emesso.

Guidance on how to interpret the contents of this table can be foundhere

0. DiagnosticReport
Definition | Laboratory Report DiagnosticReport
Short | DiagnosticReport Referto di Laboratorio
Comments | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Report, Test, Result, Results, Labs, Laboratory
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) 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 (`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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`)
2. DiagnosticReport.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. DiagnosticReport.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. DiagnosticReport.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. DiagnosticReport.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. DiagnosticReport.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. DiagnosticReport.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. DiagnosticReport.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `DiagnosticReport.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. DiagnosticReport.extension:DiagnosticReportCompositionR5
Slice Name | DiagnosticReportCompositionR5
Definition | An Extension
Short | Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Extension Definition for DiagnosticReport.composition for Version 5.0) (Extension Type: Reference(Composition))
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. DiagnosticReport.extension:DiagnosticReportCompositionR5.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
20. DiagnosticReport.extension:DiagnosticReportCompositionR5.extension
Definition | An Extension
Short | Extension
Control | 0..0
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `DiagnosticReport.extension.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
22. DiagnosticReport.extension:DiagnosticReportCompositionR5.url
Definition | Source of the definition for the extension code - a logical name or a URL.
Short | identifies the meaning of the extension
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Control | 1..1
Type | uri
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
Fixed Value | `http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition`
24. DiagnosticReport.extension:DiagnosticReportCompositionR5.value[x]
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Short | Reference a Composition.
Control | 1..1
Type | Reference(Composition - Lab Report)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. DiagnosticReport.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
28. DiagnosticReport.identifier
Definition | Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions
Short | Identificativo indipendente dalla versione.
Comments | Composition.identifier DEVE essere uguale ad uno dei DiagnosticReport.identifier, se ne esiste almeno uno.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
Type | Identifier
Is Modifier | false
Summary | true
Requirements | Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
Alternate Names | ReportID, Filler ID, Placer ID
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. DiagnosticReport.basedOn
Definition | Details concerning a service requested.
Short | Reference a una o più prestazioni richieste associate al referto.
Comments | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
Control | 0..*
Type | Reference(ServiceRequest - Lab Report)
Is Modifier | false
Summary | false
Requirements | This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Alternate Names | Request
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. DiagnosticReport.status
Definition | The status of the diagnostic report.
Short | Stato del Referto
Comments | DiagnosticReport.status e Composition.status devono essere coerenti, vedi http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus per il mapping.
Control | 1..1
Binding | The codes SHALL be taken from DiagnosticReportStatus (required to `http://hl7.org/fhir/ValueSet/diagnostic-report-status` )
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. DiagnosticReport.category
Definition | Specifies the Report Category: usually Laboratory
Short | Report Category
Comments | DiagnosticReport.category e Composition.category devono essere allineati.
Control | 0..*
Binding | For example codes, see DiagnosticServiceSectionCodes (example to `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` ) Codes for diagnostic service sections.
Type | CodeableConcept(Codeable Concept (IPS))
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `DiagnosticReport.category`. The slices areUnordered and Open, and can be differentiated using the following discriminators: pattern @ $this
36. DiagnosticReport.category:studyType
Slice Name | studyType
Definition | Laboratory services, i.e., results of tests performed, could be characterized using typology of services, commonly called study types. Study type could be seen as an attribute or grouping mechanism that assigns a common clinical sense to certain types of laboratory test results., e.g., Hemoglobin, Platelet count, etc. belongs to 'Hematology study'.
Short | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Comments | In comparison to the laboratory specialty which is an attribute of laboratory, study type is a categorization of laboratory service. It needs to be mentioned that classification of test to study types in not standardized.
Control | 0..*
Binding | The codes SHALL be taken from Laboratory Study Types (required to `http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. DiagnosticReport.category:specialty
Slice Name | specialty
Definition | Laboratory specialty is an attribute of any laboratory setting representing professional qualification of the laboratory to execute certain kind of laboratory tests.
Short | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Comments | Specialty could be used as parameter for searching/querying of laboratory test results.
Control | 0..*
Binding | The codes SHALL be taken from Laboratory Specialty (required to `http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Alternate Names | Department, Sub-department, Service, Discipline
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. DiagnosticReport.code
Definition | Specifica che il documento è un Referto di Laboratorio
Short | Referto di Laboratorio
Comments | DiagnosticReport.code e Composition.type devono essere allineati.
Control | 1..1 This element is affected by the following invariants: ele-1
Binding | The codes SHOULD be taken from Laboratory Report Types (preferred to `http://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab` )
Type | CodeableConcept(Codeable Concept (IPS))
Is Modifier | false
Alternate Names | Type
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11502-2", "display" : "Laboratory report" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. DiagnosticReport.code.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
44. DiagnosticReport.code.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `DiagnosticReport.code.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
46. DiagnosticReport.code.coding
Definition | A reference to a code defined by a terminology system.
Short | Codice definito da un sistema terminologico.
Comments | Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Coding(Coding with translations)
Is Modifier | false
Must Support | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
48. DiagnosticReport.code.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. DiagnosticReport.subject
Definition | Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).
Short | Who and/or what this report is about
Comments | DiagnosticReport e Composition devono avere lo stesso subject
Control | 1..1
Type | Reference(Patient - Lab Report)
Is Modifier | false
Summary | true
Requirements | SHALL know the subject context.
Alternate Names | Patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. DiagnosticReport.encounter
Definition | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione).
Short | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione).
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport e Composition devono referenziare lo stesso encounter.
Control | 0..1
Type | Reference(Encounter - Lab Report)
Is Modifier | false
Summary | true
Requirements | Links the request to the Encounter context.
Alternate Names | Context
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. DiagnosticReport.effective[x]
Definition | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
Short | Clinically relevant time/time-period for report.
Comments | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Control | 0..1
Type | Choice of: dateTime, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to know where in the patient history to file/present this report.
Alternate Names | Observation time, Effective Time, Occurrence
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. DiagnosticReport.issued
Definition | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.
Short | DateTime this version was made
Comments | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
Control | 0..1
Type | instant
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Clinicians need to be able to check the date that the report was released.
Alternate Names | Date published, Date Issued, Date Verified
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. DiagnosticReport.performer
Definition | Organizzazione o Persona che è responsabile del report; non è necessariamente l'autore dei dati atomici o l'entità che ha interpretato i risultati.
Short | Persona o Organizzazione che partecipa all'evento clinico descritto.
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore.
Control | 0..*
Type | Reference(Practitioner - Lab Report, PractitionerRole - Lab Report, Organization - Lab Report, CareTeam)
Is Modifier | false
Summary | true
Requirements | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Alternate Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. DiagnosticReport.resultsInterpreter
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in.
Short | Chi e/o cosa è l'autore del referto di laboratorio.
Comments | Se DiagnosticReport.resultsInterpreter esiste, anche Composition.author deve essere valorizzato. Altrimenti DiagnosticReport.performer dovrebbe essere un autore.
Control | 0..*
Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam)
Is Modifier | false
Summary | true
Requirements | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Alternate Names | Analyzed by, Reported by
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. DiagnosticReport.specimen
Definition | Details about the specimens on which this diagnostic report is based.
Short | Reference ai campioni su cui si basa la DiagnosticReport.
Comments | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Control | 0..*
Type | Reference(Specimen - Lab Report)
Is Modifier | false
Summary | false
Requirements | Need to be able to report information about the collected specimens on which the report is based.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. DiagnosticReport.result
Definition | Observations that are part of this diagnostic report.
Short | Osservazioni cliniche.
Comments | Observations can contain observations.
Control | 0..*
Type | Reference(Observation - Lab Report)
Is Modifier | false
Summary | false
Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
66. DiagnosticReport.imagingStudy
Definition | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
Short | Reference to full details of imaging associated with the diagnostic report
Comments | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Control | 0..0
Type | Reference(ImagingStudy)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
68. DiagnosticReport.media
Definition | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Short | Contenuto multimediale associate al DiagnosticReport.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | Many diagnostic services include images in the report as part of their service.
Alternate Names | DICOM, Slides, Scans
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
70. DiagnosticReport.media.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
72. DiagnosticReport.media.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
74. DiagnosticReport.media.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
76. DiagnosticReport.media.comment
Definition | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.
Short | Commento sull'immagine.
Comments | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The provider of the report should make a comment about each image included in the report.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. DiagnosticReport.media.link
Definition | Reference to the image source.
Short | Riferimento al contenuto multimediale.
Control | 1..1
Type | Reference(Media - Lab Report)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. DiagnosticReport.conclusion
Definition | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
Short | Clinical conclusion (interpretation) of test results
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to be able to provide a conclusion that is not lost among the basic result data.
Alternate Names | Report
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
82. DiagnosticReport.conclusionCode
Definition | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.
Short | Codes for the clinical conclusion of test results
Control | 0..*
Binding | For example codes, see SNOMEDCTClinicalFindings (example to `http://hl7.org/fhir/ValueSet/clinical-findings` ) Diagnosis codes provided as adjuncts to the report.
Type | CodeableConcept
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
84. DiagnosticReport.presentedForm
Definition | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Short | Rappresentazione testuale del Referto di Laboratorio così come emesso.
Comments | "application/pdf" is recommended as the most reliable and interoperable in this context.
Control | 0..*
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)