Botswana FHIR Implementation Guide - Laboratory
1.0.0 - STU1
Botswana FHIR Implementation Guide - Laboratory
1.0.0 - STU1
Botswana FHIR Implementation Guide - Laboratory, published by Jembi Health Systems. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/jembi/bw-laboratory-workflows-ig/ and changes regularly. See the Directory of published versions
| Official URL: http://moh.bw.org/StructureDefinition/uat-pims-diagnostic-report | Version: 1.0.0 | |||
| Active as of 2024-08-28 | Computable Name: PimsUATDiagnosticReport | |||
Represents the results for the lab order.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from GenericUATDiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |
 result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
  category |
Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. 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: 11502-2 | |
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
| text |
Σ | 1..1 | string | Plain text representation of the concept |
| subject |
Σ | 1..1 | Reference(Patient - PIMS | Patient - OpenMRS) | The subject of the report - usually, but not always, the patient |
| encounter |
SΣ | 0..1 | Reference(Encounter - Initiated By The Facility Providing the Service) | Health care event when test ordered |
| issued |
Σ | 1..1 | instant | DateTime this version was made |
| performer |
Σ | 1..* | Reference(Practitioner - General Practitioner | Organization) | Responsible Diagnostic Service |
| result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | example | Pattern: LOINC Code 11502-2http://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| 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 | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |||||
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category |
Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. 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: 11502-2 | |||||
| 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 | |||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text |
Σ | 1..1 | string | Plain text representation of the concept | ||||
| subject |
Σ | 1..1 | Reference(Patient - PIMS | Patient - OpenMRS) | The subject of the report - usually, but not always, the patient | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter - Initiated By The Facility Providing the Service) | Health care event when test ordered | ||||
 effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
Σ | 1..1 | instant | DateTime this version was made | ||||
| performer |
Σ | 1..* | Reference(Practitioner - General Practitioner | Organization) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | example | Pattern: LOINC Code 11502-2http://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from GenericUATDiagnosticReport
Differential View
This structure is derived from GenericUATDiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |
| result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
| category |
Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. 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: 11502-2 | |
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
| text |
Σ | 1..1 | string | Plain text representation of the concept |
| subject |
Σ | 1..1 | Reference(Patient - PIMS | Patient - OpenMRS) | The subject of the report - usually, but not always, the patient |
| encounter |
SΣ | 0..1 | Reference(Encounter - Initiated By The Facility Providing the Service) | Health care event when test ordered |
| issued |
Σ | 1..1 | instant | DateTime this version was made |
| performer |
Σ | 1..* | Reference(Practitioner - General Practitioner | Organization) | Responsible Diagnostic Service |
| result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | example | Pattern: LOINC Code 11502-2http://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | GenericUATDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| 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 | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
1..* | Reference(Service Request - PIMS Lab Orders) | What was requested | |||||
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category |
Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. 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: 11502-2 | |||||
| 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 | |||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text |
Σ | 1..1 | string | Plain text representation of the concept | ||||
| subject |
Σ | 1..1 | Reference(Patient - PIMS | Patient - OpenMRS) | The subject of the report - usually, but not always, the patient | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter - Initiated By The Facility Providing the Service) | Health care event when test ordered | ||||
| effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
Σ | 1..1 | instant | DateTime this version was made | ||||
| performer |
Σ | 1..* | Reference(Practitioner - General Practitioner | Organization) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
1..* | Reference(Observation - PIMS Diagnostic Test Result) | Observations | |||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | example | Pattern: LOINC Code 11502-2http://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from GenericUATDiagnosticReport
Other representations of profile: CSV, Excel, Schematron