DK MedCom Core
2.4.0 - release
DK MedCom Core
2.4.0 - release
DK MedCom Core, published by MedCom. This guide is not an authorized publication; it is the continuous build for version 2.4.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/medcomdk/dk-medcom-core/ and changes regularly. See the Directory of published versions
| Official URL: http://medcomfhir.dk/ig/core/StructureDefinition/medcom-core-diagnosticreport | Version: 2.4.0 | |||
| Active as of 2024-09-26 | Computable Name: MedComCoreDiagnosticReport | |||
Report containing all observation results.
Note: This profile is developed to be part of a production trial of the communication between the general practitioner and municipal acute care team.
This profile is intended to be uses in MedCom HomeCareObservation and MedCom's Laboratory standards.
In MedComCoreDiagnosticReport it is allowed to include attachments. When sending an attachment diagnosticReport.media shall be used. The DiagnosticReport.media.link reference to MedComCoreMedia resource where the atachment shall be added. It is up to the user to assess when it is relevant to send an attachment. Only an attachment of the permitted formats must be included. Click here to see the permitted formats of an attachment
If a patient gives a negative consent to sharing the observation results with other than the general practitioner a security labe shall be used. This mean that the meta.security.code shall be R, and in the user interface, it shall be clearly stated that consent has been refused.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  status |
S | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) |
| code |
S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) |
 subject |
S | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient |
| issued |
S | 1..1 | instant | DateTime this version was made |
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| result |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations |
 media |
S | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. |
  link |
S | 1..1 | Reference(MedComMedia) | Reference to the image source |
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | 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 |
| status |
?!SΣ | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) |
 code |
SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) |
| subject |
SΣ | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient |
| issued |
SΣ | 1..1 | instant | DateTime this version was made |
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| result |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations |
| media |
SΣ | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link |
SΣ | 1..1 | Reference(MedComMedia) | Reference to the image source |
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset |
| 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..* | DiagnosticReport | 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 |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) | ||||
| category |
Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) | ||||
| subject |
SΣ | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
 effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 1..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
SΣ | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. | ||||
| 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 |
SΣ | 1..1 | Reference(MedComMedia) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. | ||||
| 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 | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset | ||||
| 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 DiagnosticReport
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| status |
S | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) |
| code |
S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) |
| subject |
S | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient |
| issued |
S | 1..1 | instant | DateTime this version was made |
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| result |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations |
| media |
S | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. |
| link |
S | 1..1 | Reference(MedComMedia) | Reference to the image source |
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | 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 |
| status |
?!SΣ | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) |
| code |
SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) |
| subject |
SΣ | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient |
| issued |
SΣ | 1..1 | instant | DateTime this version was made |
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| result |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations |
| media |
SΣ | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link |
SΣ | 1..1 | Reference(MedComMedia) | Reference to the image source |
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset |
| 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..* | DiagnosticReport | 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 |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: MedComCoreDiagnosticReportStatus (required) | ||||
| category |
Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required) | ||||
| subject |
SΣ | 1..1 | Reference(MedComCorePatient) {b} | The subject of the report - usually, but not always, the patient | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 1..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 |
S | 0..* | Reference(MedComCoreObservation) {b} | Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
SΣ | 0..* | BackboneElement | Attachments that are relevant for assessment of the patient's condition. | ||||
| 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 |
SΣ | 1..1 | Reference(MedComMedia) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | A comment relevant for all observations in the report. | ||||
| 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 | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | MedComCoreDiagnosticReportStatushttp://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticreport-status | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValuesethttp://medcomfhir.dk/ig/terminology/ValueSet/MedComDiagnosticReportCodesValueset | ||||
| 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 DiagnosticReport
Other representations of profile: CSV, Excel, Schematron