HL7 Europe Laboratory Report
0.1.0-ballot - ballot
150
HL7 Europe Laboratory Report
0.1.0-ballot - ballot
150
This page is part of the HL7 Europe Laboratory Report (v0.1.0-ballot: STU 1 Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.eu/fhir/laboratory/StructureDefinition/Composition-eu-lab | Version: 0.1.0-ballot | |||
| Standards status: Draft | Maturity Level: 1 | Computable Name: CompositionLabReportEu | ||
Copyright/Legal: Used by permission of HL7 Europe, all rights reserved Creative Commons License |
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Clinical document used to represent a Laboratory Report for the scope of the HL7 Europe project.
DiagnosticReport as possible entryThe first design of the Laboratory Report foresaw that only Observations were referred by the Composition.section.entry.
The idea is that when a group of results needed to be managed, the Observation resource is used for this scope.
This choice seems however not yet globally agreed. In some contexts in fact the DiagnosticReport is used not only to represent a complete report, but also a grouper of Laboratory results (e.g. panel).
For this reason, we are evaluating also the option of having a DiagnosticReport as possible entry has been added.
Ballotters are invited to express their opinions on this possible choice
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Clinical Document | Laboratory Report composition | |
  text | 0..1 | Narrative | Narrative text | |
  basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
   Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Open by type:$this | |
  value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
| identifier | 0..1 | Identifier | Report identifier | |
| status | 1..1 | code | Status of the Report | |
 type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
| Slices for category | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this | |
 category:studyType | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) | |
| category:specialty | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) | |
 subject | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | |
| encounter | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | |
| author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | |
| title | 1..1 | string | Laboratory Report | |
| attester | 0..* | BackboneElement | Attests the report accuracy | |
| mode | 1..1 | code | The type of attestation | |
| time | 0..1 | dateTime | When the report was attested by the party | |
 party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
| event | 0..* | BackboneElement | The laboratory service(s) being documented | |
| code | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented | |
| period | 0..1 | Period | Period of time covered by the documentation | |
| detail | 0..* | Reference(Resource) | The laboratory service(s) being documented | |
 Slices for section | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | |
 section:All Slices | Content/Rules for all slices | |||
 title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | |
| section:lab-no-subsections | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | |
 code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
| entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
 section | 0..0 | |||
| section:lab-subsections | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | 0..0 | |||
| entry | 0..0 | |||
| section | 1..* | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
| entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
| section | 0..0 | |||
 section:annotations | 0..* | BackboneElement | Annotation comment | |
 code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
| text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
| entry | 0..0 | |||
| section | 0..0 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | preferred | LabReportTypesEuVs |
| Composition.category:studyType | required | LabStudyTypesEuVs |
| Composition.category:specialty | required | LabSpecialtyEuVs |
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | Laboratory Report composition | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| text | 0..1 | Narrative | Narrative text | |
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
 extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Report identifier |
| status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| category:studyType | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) |
| category:specialty | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) |
| subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about |
| encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report |
| title | Σ | 1..1 | string | Laboratory Report |
| attester | 0..* | BackboneElement | Attests the report accuracy | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the report was attested by the party | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | Period of time covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented |
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
| section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| section | C | 1..* | BackboneElement | Nested Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
| section:annotations | C | 0..* | BackboneElement | Annotation comment |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
| text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | LabReportTypesEuVs |
| Composition.category | example | DocumentClassValueSet |
| Composition.category:studyType | required | LabStudyTypesEuVs |
| Composition.category:specialty | required | LabSpecialtyEuVs |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.event.code | example | ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs |
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Clinical Document | Laboratory Report composition | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Narrative text | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Report identifier | ||||
| status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:studyType | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
| date | Σ | 1..1 | dateTime | Composition editing time | ||||
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | ||||
| title | Σ | 1..1 | string | Laboratory Report | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests the report accuracy | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | Period of time covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 1..* | BackboneElement | Nested Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:annotations | C | 0..* | BackboneElement | Annotation comment | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LabReportTypesEuVs | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.category:studyType | required | LabStudyTypesEuVs | ||||
| Composition.category:specialty | required | LabSpecialtyEuVs | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-no-subsections.mode | required | ListMode | ||||
| Composition.section:lab-no-subsections.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-no-subsections.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-subsections.mode | required | ListMode | ||||
| Composition.section:lab-subsections.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-subsections.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-subsections.section.mode | required | ListMode | ||||
| Composition.section:lab-subsections.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-subsections.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8 | ||||
| Composition.section:annotations.mode | required | ListMode | ||||
| Composition.section:annotations.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:annotations.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Clinical Document
Summary
Mandatory: 4 elements (6 nested mandatory elements)
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | Laboratory Report composition | |
| text | 0..1 | Narrative | Narrative text | |
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Open by type:$this | |
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
| identifier | 0..1 | Identifier | Report identifier | |
| status | 1..1 | code | Status of the Report | |
| type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
| Slices for category | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this | |
| category:studyType | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) | |
| category:specialty | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) | |
| subject | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | |
| encounter | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | |
| author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | |
| title | 1..1 | string | Laboratory Report | |
| attester | 0..* | BackboneElement | Attests the report accuracy | |
| mode | 1..1 | code | The type of attestation | |
| time | 0..1 | dateTime | When the report was attested by the party | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
| event | 0..* | BackboneElement | The laboratory service(s) being documented | |
| code | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented | |
| period | 0..1 | Period | Period of time covered by the documentation | |
| detail | 0..* | Reference(Resource) | The laboratory service(s) being documented | |
| Slices for section | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | |
| section:All Slices | Content/Rules for all slices | |||
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | |
| section:lab-no-subsections | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
| entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
| section | 0..0 | |||
| section:lab-subsections | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | 0..0 | |||
| entry | 0..0 | |||
| section | 1..* | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation. | |
| entry | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | |
| section | 0..0 | |||
| section:annotations | 0..* | BackboneElement | Annotation comment | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
| text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
| entry | 0..0 | |||
| section | 0..0 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | preferred | LabReportTypesEuVs |
| Composition.category:studyType | required | LabStudyTypesEuVs |
| Composition.category:specialty | required | LabSpecialtyEuVs |
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | Laboratory Report composition | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| text | 0..1 | Narrative | Narrative text | |
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Report identifier |
| status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| category:studyType | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) |
| category:specialty | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) |
| subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about |
| encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report |
| title | Σ | 1..1 | string | Laboratory Report |
| attester | 0..* | BackboneElement | Attests the report accuracy | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the report was attested by the party | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | Period of time covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented |
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
| section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |
| section | C | 1..* | BackboneElement | Nested Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. |
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section |
| section:annotations | C | 0..* | BackboneElement | Annotation comment |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |
| text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | LabReportTypesEuVs |
| Composition.category | example | DocumentClassValueSet |
| Composition.category:studyType | required | LabStudyTypesEuVs |
| Composition.category:specialty | required | LabSpecialtyEuVs |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.event.code | example | ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs |
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs |
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Clinical Document | Laboratory Report composition | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Narrative text | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Report identifier | ||||
| status | ?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:studyType | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient: Person | Patient: Animal | Group | Location | Device) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
| date | Σ | 1..1 | dateTime | Composition editing time | ||||
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the Laboratory Report | ||||
| title | Σ | 1..1 | string | Laboratory Report | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests the report accuracy | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | Period of time covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variant 1: EU Laboratory Report section with entries and no sub-sections | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 1..* | BackboneElement | Nested Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:annotations | C | 0..* | BackboneElement | Annotation comment | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LabReportTypesEuVs | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.category:studyType | required | LabStudyTypesEuVs | ||||
| Composition.category:specialty | required | LabSpecialtyEuVs | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-no-subsections.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-no-subsections.mode | required | ListMode | ||||
| Composition.section:lab-no-subsections.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-no-subsections.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-subsections.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-subsections.mode | required | ListMode | ||||
| Composition.section:lab-subsections.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-subsections.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVs | ||||
| Composition.section:lab-subsections.section.mode | required | ListMode | ||||
| Composition.section:lab-subsections.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:lab-subsections.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8 | ||||
| Composition.section:annotations.mode | required | ListMode | ||||
| Composition.section:annotations.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:annotations.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Clinical Document
Summary
Mandatory: 4 elements (6 nested mandatory elements)
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 Europe. Package hl7.fhir.eu.laboratory#0.1.0-ballot based on FHIR 4.0.1. Generated 2023-10-22
