Generated Narrative: StructureDefinition diagnosticReport-eu-core Name Flags Card. Type Description & Constraints DiagnosticReport 0..* DiagnosticReport Diagnostic Report EU core #xD; language 0..1 code Language of the diagnostic report content #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:DiagnosticReportCompositionR5 0..1 (Complex) Associated Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition #xD; extension 0..0 Extension #xD; value[x] 1..1 Reference(Composition (EU core)) Reference to a Composition resource for the DiagnosticReport structure #xD; extension:note 0..* (Complex) R5: Comments about the diagnostic report (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note #xD; extension 0..0 Extension #xD; value[x] #xD; Slices for extension Content/Rules for all slices #xD; extension:annotation-type 0..* (Complex) The type of annotation URL: http://hl7.org/fhir/StructureDefinition/annotationType #xD; value[x] 1..1 CodeableConcept Type of note #xD; identifier 0..* Identifier Business identifier for report #xD; status 1..1 code Status of the Report #xD; code 1..1 CodeableConcept Type of Diagnostic Report #xD; subject 1..1 Reference(Patient | Group | Location | Device) Who and/or what this report is about #xD; encounter 0..1 Reference(Encounter) The healthcare event which this Diagnostic Report is about (when test ordered). #xD; Slices for effective[x] 0..1 dateTime, Period Clinically relevant time/time-period for report. Slice: Unordered, Open by type:$this #xD; effective[x]:effectivePeriod 0..1 Period Effective period of the report #xD; issued 0..1 instant Date and time this report was issued #xD; Slices for performer 0..* Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | CareTeam) Responsible Diagnostic Service. Slice: Unordered, Open by profile:$this #xD; performer:organization 0..* Reference(Organization (EU core)) The organization producer of this report #xD; Slices for resultsInterpreter 0..* Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | CareTeam) Primary result interpreter Slice: Unordered, Open by profile:resolve() #xD; resultsInterpreter:author 0..* Reference(PractitionerRole (EU core)) Primary result interpreter #xD; specimen 0..* Reference(Specimen) Specimens this report is based on. #xD; result 0..* Reference(Observation) results #xD; imagingStudy 0..* Reference(ImagingStudy) Study subject to this report #xD; media 0..* BackboneElement Additional data (like images, diagrams or documents) associated with this report #xD; comment 0..1 string Comment about the image or data (e.g. explanation) #xD; link 1..1 Reference(Media) Reference to the image or data #xD; presentedForm 0..* Attachment Entire report as issued (pdf recommended) #xD; Documentation for this format
This profile introduces essential constraints and extensions for the DiagnosticReport resource that apply across multiple use cases.
Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0).
This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Observation[classCode=OBS, moodCode=EVN]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Language of the diagnostic report content
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
This extension implements the R5 composition element. It allow to link this DiagnosticReport with the Composition documenting this Diagnostic Report.
Element `DiagnosticReport.composition` has a context of DiagnosticReport based on following the parent source element upwards and mapping to `DiagnosticReport`. Element `DiagnosticReport.composition` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element). The Composition provides structure to the content of the DiagnosticReport (and only contains contents referenced in the DiagnosticReport) - e.g., to order the sections of an anatomic pathology structured report.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Source of the definition for the extension code - a logical name or a URL.
The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Reference to a Composition resource for the DiagnosticReport structure
Reference to a Composition resource instance that provides structure for organizing the contents of the DiagnosticReport.
The Composition provides structure to the content of the DiagnosticReport (and only contains contents referenced in the DiagnosticReport) - e.g., to order the sections of an anatomic pathology structured report.
R5: Comments about the diagnostic report (new)
R5: `DiagnosticReport.note` (new:Annotation)
Element `DiagnosticReport.note` has a context of DiagnosticReport based on following the parent source element upwards and mapping to `DiagnosticReport`. Element `DiagnosticReport.note` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element). May include general statements about the diagnostic report, or statements about significant, unexpected or unreliable results values contained within the diagnostic report, or information about its source when relevant to its interpretation.
May include general statements about the diagnostic report, or statements about significant, unexpected or unreliable results values contained within the diagnostic report, or information about its source when relevant to its interpretation.
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
The type of annotation. This extension can be used to map the v2 NTE-4 comment type field.
This is used to identify the type of annotation.
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R5/extensibility.html) for a list).
Individual responsible for the annotation
The individual responsible for making the annotation.
Organization is used when there's no need for specific attribution as to who made the comment.
Indicates when this particular annotation was made.
The annotation - text content (as markdown)
The text of the annotation in markdown format.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Identifiers assigned to this report by the performer or other systems.
Usually assigned by the Information System of the diagnostic service provider for facilitating the Report search. The order id can be used as one of the Report identifier if only one report is produced for that order.
Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
DiagnosticReport.status and Composition.status shall be aligned
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
Defines the document type, it is recommended to take this from the suggested LOINC set.
OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).
PID-3 (no HL7 v2 mapping for Group or Device)
The healthcare event which this Diagnostic Report is about (when test ordered).
The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Links the request to the Encounter context.
inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Clinically relevant time/time-period for report.
The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Need to know where in the patient history to file/present this report.
The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.
May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
Clinicians need to be able to check the date that the report was released.
The diagnostic service that is responsible for issuing the report.
If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author.
Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
PRT-8 (where this PRT-4-Participation = "PO")
The organization producer of this report
The organization responsible for producing this report. In case practitioners produce them in their private practices, they will be accounted as an organization for this purpose.
This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
The practitioner or organization that is responsible for the report's conclusions and interpretations.
OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
Might not be the same entity that takes responsibility for the clinical report.
Details about the specimens on which this diagnostic report is based.
If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Need to be able to report information about the collected specimens on which the report is based.
[Observations](http://hl7.org/fhir/R4/observation.html) that are part of this diagnostic report.
Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
Additional data (like images, diagrams or documents) associated with this report
A list of additional data, other then presented form of the report, associated with this report. This data is generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Some diagnostic reports may include additional data such as images, diagrams or documents that are relevant to the report. This additional information can provide further context and support for the findings presented in the report.
DICOM; Slides; Scans; Pictures; Documents; Diagrams
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Comment about the image or data (e.g. explanation)
Allows for a comment about the image or data, such as an explanation of its significance or context within the diagnostic report.
The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
The provider of the report should make a comment about each image or data included in the report. This comment can provide valuable context and help the reader understand the significance of the image or data in relation to the overall findings of the report.
.inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value
A reference to the image or data associated with this report.
Clinical conclusion (interpretation) of test results
Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
Need to be able to provide a conclusion that is not lost among the basic result data.
inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
Codes for the clinical conclusion of test results
One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.
Diagnosis codes provided as adjuncts to the report.
inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
Entire report as issued (pdf recommended)
Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
"application/pdf" is recommended as the most reliable and interoperable in this context.
Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.