HL7 Europe Base and Core FHIR IG
2.0.0-ballot - ballot 150

HL7 Europe Base and Core FHIR IG - Downloaded Version 2.0.0-ballot See the Directory of published versions

## Resource Profile: DiagnosticReport (EU core)

Official URL: http://hl7.eu/fhir/base-r5/StructureDefinition/diagnosticReport-eu-core | Version: 2.0.0-ballot
Standards status: Draft | Maturity Level: 1 | Computable Name: DiagnosticReportEuCore
Copyright/Legal: Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0).

This profile sets minimum expectations for the DiagnosticReport resource for commonly used EHDS documents.

Usages:

- Examples for this Profile: DiagnosticReport/5679723c-4fae-4ba7-9f09-5438a827bfda

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | Diagnostic Report EU core Constraints: dgr-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 1..1 | Annotation | Value of extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/annotationType"
value[x] |  | 1..1 | CodeableConcept | Type of note Binding: hl7VS-commentType (example)
text | Σ | 1..1 | markdown | The annotation - text content (as markdown)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | Status of the Report Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | Σ | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:diagnostic-service | Σ | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code | Σ | 1..1 | CodeableConcept | Type of Diagnostic Report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report.
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
Slices for performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization | Σ | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author | Σ | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result | C | 0..* | Reference(Observation) | results
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
media | Σ | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📦2.0.0 | THO v7.0
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.
DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | Diagnostic Report EU core
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
value[x] |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
value[x] |  | 1..1 | CodeableConcept | Type of note
identifier |  | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status |  | 1..1 | code | Status of the Report
Slices for category |  | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this
category:diagnostic-service |  | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code |  | 1..1 | CodeableConcept | Type of Diagnostic Report
subject |  | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter |  | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] |  | 0..1 | dateTime, Period | Clinically relevant time/time-period for report.
Slices for performer |  | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization |  | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter |  | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author |  | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result |  | 0..* | Reference(Observation) | results
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
media |  | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link |  | 1..1 | Reference(DocumentReference) | Reference to the image or data
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | Diagnostic Report EU core Constraints: dgr-1
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: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 1..1 | Annotation | Value of extension
id |  | 0..1 | id | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/annotationType"
value[x] |  | 1..1 | CodeableConcept | Type of note Binding: hl7VS-commentType (example)
author[x] | Σ | 0..1 |  | Individual responsible for the annotation
authorReference |  |  | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Organization) |
authorString |  |  | string |
time | Σ | 0..1 | dateTime | When the annotation was made
text | Σ | 1..1 | markdown | The annotation - text content (as markdown)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | Status of the Report Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | Σ | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:diagnostic-service | Σ | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code | Σ | 1..1 | CodeableConcept | Type of Diagnostic Report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report.
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
Slices for performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization | Σ | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author | Σ | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result | C | 0..* | Reference(Observation) | results
note |  | 0..* | Annotation | Comments about the diagnostic report
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
supportingInfo |  | 0..* | BackboneElement | Additional information supporting the diagnostic 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
type |  | 1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report.
reference |  | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference
media | Σ | 0..* | BackboneElement | Additional data (like images, diagrams or documents) 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 or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data
composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure
conclusion |  | 0..1 | markdown | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📦2.0.0 | THO v7.0
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.
DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.supportingInfo.​type | Base | example | hl7VS-VS-observationType | 📦2.0.0 | THO v7.0
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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: 1 element(1 nested mandatory element)

Structures

This structure refers to these other structures:

- Composition (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/composition-eu-core)
- Patient (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/patient-eu-core)
- Patient: Animal (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/patient-animal-eu-core)
- Organization (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/organization-eu-core)
- PractitionerRole (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/practitionerRole-eu-core)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
- http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
- http://hl7.org/fhir/StructureDefinition/annotationType

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.category
- The element 1 is sliced based on the value of DiagnosticReport.performer
- The element 1 is sliced based on the value of DiagnosticReport.resultsInterpreter

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | Diagnostic Report EU core Constraints: dgr-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 1..1 | Annotation | Value of extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/annotationType"
value[x] |  | 1..1 | CodeableConcept | Type of note Binding: hl7VS-commentType (example)
text | Σ | 1..1 | markdown | The annotation - text content (as markdown)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | Status of the Report Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | Σ | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:diagnostic-service | Σ | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code | Σ | 1..1 | CodeableConcept | Type of Diagnostic Report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report.
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
Slices for performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization | Σ | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author | Σ | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result | C | 0..* | Reference(Observation) | results
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
media | Σ | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📦2.0.0 | THO v7.0
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.
DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()`

Differential View

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | Diagnostic Report EU core
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
value[x] |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
value[x] |  | 1..1 | CodeableConcept | Type of note
identifier |  | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status |  | 1..1 | code | Status of the Report
Slices for category |  | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this
category:diagnostic-service |  | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code |  | 1..1 | CodeableConcept | Type of Diagnostic Report
subject |  | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter |  | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] |  | 0..1 | dateTime, Period | Clinically relevant time/time-period for report.
Slices for performer |  | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization |  | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter |  | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author |  | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result |  | 0..* | Reference(Observation) | results
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
media |  | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link |  | 1..1 | Reference(DocumentReference) | Reference to the image or data
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | Diagnostic Report EU core Constraints: dgr-1
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: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 0..1 | (Complex) | Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition (EU core)) | Value of extension
extension:note |  | 0..* | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 1..1 | Annotation | Value of extension
id |  | 0..1 | id | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:annotation-type |  | 0..* | (Complex) | The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/annotationType"
value[x] |  | 1..1 | CodeableConcept | Type of note Binding: hl7VS-commentType (example)
author[x] | Σ | 0..1 |  | Individual responsible for the annotation
authorReference |  |  | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Organization) |
authorString |  |  | string |
time | Σ | 0..1 | dateTime | When the annotation was made
text | Σ | 1..1 | markdown | The annotation - text content (as markdown)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | Status of the Report Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | Σ | 0..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:diagnostic-service | Σ | 0..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (required)
code | Σ | 1..1 | CodeableConcept | Type of Diagnostic Report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Diagnostic Report is about (when test ordered).
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report.
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
Slices for performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this
performer:organization | Σ | 0..* | Reference(Organization (EU core)) | The organization producer of this report
Slices for resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Slice: Unordered, Open by profile:resolve()
resultsInterpreter:author | Σ | 0..* | Reference(PractitionerRole (EU core)) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on.
result | C | 0..* | Reference(Observation) | results
note |  | 0..* | Annotation | Comments about the diagnostic report
study |  | 0..* | Reference(GenomicStudy | ImagingStudy) | Study subject to this report
supportingInfo |  | 0..* | BackboneElement | Additional information supporting the diagnostic 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
type |  | 1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report.
reference |  | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference
media | Σ | 0..* | BackboneElement | Additional data (like images, diagrams or documents) 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 or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data
composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure
conclusion |  | 0..1 | markdown | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📦2.0.0 | THO v7.0
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:diagnostic-service | Base | required | Diagnostic Service Section Codes | 📦5.0.0 | FHIR Std.
DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.supportingInfo.​type | Base | example | hl7VS-VS-observationType | 📦2.0.0 | THO v7.0
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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: 1 element(1 nested mandatory element)

Structures

This structure refers to these other structures:

- Composition (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/composition-eu-core)
- Patient (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/patient-eu-core)
- Patient: Animal (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/patient-animal-eu-core)
- Organization (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/organization-eu-core)
- PractitionerRole (EU core) (http://hl7.eu/fhir/base-r5/StructureDefinition/practitionerRole-eu-core)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
- http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note
- http://hl7.org/fhir/StructureDefinition/annotationType

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.category
- The element 1 is sliced based on the value of DiagnosticReport.performer
- The element 1 is sliced based on the value of DiagnosticReport.resultsInterpreter

Maturity: 1

Other representations of profile: CSV, Excel, Schematron