ImplementationGuide for Malaysia Core (MY Core)
0.0.1 - CI Build
ImplementationGuide for Malaysia Core (MY Core)
0.0.1 - CI Build
ImplementationGuide for Malaysia Core (MY Core), published by Malaysia Healthcare Nexus (MHN). This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/nhphong245/my-core-ig-r4/ and changes regularly. See the Directory of published versions
| Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/DiagnosticReport-my-core | Version: 0.0.1 | |||
| Active as of 2024-03-13 | Responsible: Malaysia Healthcare Nexus (MHN) |
Realm: 
|
Computable Name: DiagnosticReportMyCore | |
This profile constrains the DiagnosticReport resource to represent diagnostic test and procedure reports in a patient summary.
This profile constrains the DiagnosticReport resource to use the specific MY Core profiles for observations and coded data types.
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 | |
  Slices for extension |
Content/Rules for all slices | |||
   printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |
 attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |
 category |
1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
 Slices for coding |
0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
  coding:serviceRequestCategory |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) | |
  system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core | |
| coding:imagingModality |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core | |
| coding:imagingRegion |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core | |
 coding:labSubGroup |
0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core | |
| code |
1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) | |
| Slices for coding |
0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
| coding:lab |
0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core | |
| coding:imaging |
0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core | |
| coding:loinc |
0..* | Coding | Code defined by a terminology system | |
| system |
0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 subject |
1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | |
| encounter |
1..1 | Reference(Encounter) | Health care event when test ordered | |
 conclusion |
1..1 | string | Clinical conclusion (interpretation) of test results | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodes | |
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | |
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | |
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | |
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | |
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG |
| 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 |
| Slices for extension |
Content/Rules for all slices | |||
| printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |
| attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
 category |
Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) |
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
| coding:serviceRequestCategory |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core |
| coding:imagingModality |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core |
| coding:imagingRegion |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core |
| coding:labSubGroup |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core |
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) |
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
| coding:lab |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core |
| coding:imaging |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core |
| coding:loinc |
Σ | 0..* | Coding | Code defined by a terminology system |
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
 subject |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter |
Σ | 1..1 | Reference(Encounter) | Health care event when test ordered |
| conclusion |
1..1 | string | Clinical conclusion (interpretation) of test results | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | |
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | |
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | |
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | |
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG |
| 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 | |||||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |||||
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |||||
| attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |||||
| 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 |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category |
Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
| coding:serviceRequestCategory |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) | ||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imagingModality |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imagingRegion |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:labSubGroup |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
| coding:lab |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imaging |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:loinc |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter |
Σ | 1..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 |
Σ | 0..1 | instant | DateTime this version was made | ||||
| performer |
Σ | 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 |
0..* | Reference(Observation) | 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 |
1..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 | 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 | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | ||||
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | ||||
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | ||||
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG | ||||
| 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
Summary
Mandatory: 4 elements(6 nested mandatory elements)
Fixed: 7 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
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 | |
| Slices for extension |
Content/Rules for all slices | |||
| printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |
| attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |
| category |
1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
| Slices for coding |
0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
| coding:serviceRequestCategory |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core | |
| coding:imagingModality |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core | |
| coding:imagingRegion |
0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core | |
| coding:labSubGroup |
0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core | |
| code |
1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) | |
| Slices for coding |
0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
| coding:lab |
0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core | |
| coding:imaging |
0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core | |
| coding:loinc |
0..* | Coding | Code defined by a terminology system | |
| system |
0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| subject |
1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | |
| encounter |
1..1 | Reference(Encounter) | Health care event when test ordered | |
| conclusion |
1..1 | string | Clinical conclusion (interpretation) of test results | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodes | |
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | |
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | |
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | |
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | |
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG |
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 |
| Slices for extension |
Content/Rules for all slices | |||
| printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |
| attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
| category |
Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) |
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
| coding:serviceRequestCategory |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core |
| coding:imagingModality |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core |
| coding:imagingRegion |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core |
| coding:labSubGroup |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core |
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) |
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
| coding:lab |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core |
| coding:imaging |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) |
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core |
| coding:loinc |
Σ | 0..* | Coding | Code defined by a terminology system |
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
| subject |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter |
Σ | 1..1 | Reference(Encounter) | Health care event when test ordered |
| conclusion |
1..1 | string | Clinical conclusion (interpretation) of test results | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | |
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | |
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | |
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | |
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | |
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG |
| 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 | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| printedDate |
0..1 | dateTime | Extension about the DiagnosticReport date printed URL: http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core | |||||
| amendment |
0..1 | (Complex) | Extension to add amended information of this clinical documentation URL: http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core | |||||
| attachmentBoolean |
0..1 | boolean | Extension to determine whether this DiagnosticReport provides any external attachment URL: http://fhir.hie.moh.gov.my/StructureDefinition/attachment-boolean-my-core | |||||
| 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 |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category |
Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
| coding:serviceRequestCategory |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetServiceRequestCategory( MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imagingModality |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingModality (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-modality-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imagingRegion |
Σ | 0..1 | Coding | Code defined by a terminology system Binding: ValueSetImagingRegion (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-region-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:labSubGroup |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLabSubGroup (MY Core) (example) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-sub-group-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: ValueSetLoinc (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
| coding:lab |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetLab (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/lab-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:imaging |
Σ | 0..* | Coding | Code defined by a terminology system Binding: ValueSetImaging (MY Core) (preferred) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/imaging-my-core | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:loinc |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter |
Σ | 1..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 |
Σ | 0..1 | instant | DateTime this version was made | ||||
| performer |
Σ | 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 |
0..* | Reference(Observation) | 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 |
1..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 | 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 | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.category.coding:serviceRequestCategory | preferred | ValueSetServiceRequestCategoryMyCore (a valid code from CodeSystemServiceRequestCategory (MY Core))http://fhir.hie.moh.gov.my/ValueSet/servicerequest-category-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:imagingModality | preferred | ValueSetImagingModalityMyCore (a valid code from CodeSystemImagingModality (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-modality-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:imagingRegion | preferred | ValueSetImagingRegionMyCore (a valid code from CodeSystemImagingRegion (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-region-my-corefrom this IG | ||||
| DiagnosticReport.category.coding:labSubGroup | example | ValueSetLabSubGroupMyCore (a valid code from CodeSystemLabSubGroup (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-sub-group-my-corefrom this IG | ||||
| DiagnosticReport.code | preferred | ValueSetLoincMyCore (a valid code from LOINC)http://fhir.hie.moh.gov.my/ValueSet/loinc-my-corefrom this IG | ||||
| DiagnosticReport.code.coding:lab | preferred | ValueSetLabMyCore (a valid code from CodeSystemLab (MY Core))http://fhir.hie.moh.gov.my/ValueSet/lab-my-corefrom this IG | ||||
| DiagnosticReport.code.coding:imaging | preferred | ValueSetImagingMyCore (a valid code from CodeSystemImaging (MY Core))http://fhir.hie.moh.gov.my/ValueSet/imaging-my-corefrom this IG | ||||
| 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
Summary
Mandatory: 4 elements(6 nested mandatory elements)
Fixed: 7 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ Malaysia Healthcare Nexus (MHN). Package fhir.my.ig.r4#0.0.1 based on FHIR 4.0.1. Generated 2024-10-18
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