HL7 Europe Laboratory Report
2.0.0 - ci-build 150

HL7 Europe Laboratory Report - Downloaded Version 2.0.0 See the Directory of published versions

## Resource Profile: DiagnosticReport: Laboratory Report

Official URL: http://hl7.eu/fhir/laboratory/StructureDefinition/DiagnosticReport-eu-lab | Version: 2.0.0
Standards status: Trial-use | Maturity Level: 2 | Computable Name: DiagnosticReportLabEu
Copyright/Legal: Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0).

DiagnosticReport used to represent an entry of a Laboratory Report, including its context, for the scope of the HL7 Europe project.

> #### Previous results

> This version of the guide uses the supportingInfo extension to the Observation lab results, for conveying the previous.

> Implementers are invited to provide their feedback about the possible adoption of the supportingInfo extension to this DiagnosticReport profile

#### Adding a PDF, images or other kind of additional data in a DiagnosticReport

In some cases it is requested to include PDF, images or other kind of additional data in a Diagnostic Report.

If the PDF to be added is the representation of the entire Laboratory report, then this will be recorded in the optional element presentedForm

In case of images or other kinds of additional data (that can be a pdf document) used as support for the interpretation of the report, this is realized by using the optional element media.

#### Sorting of laboratory study groups and results

The order of laboratory study groups as well the results within these groups are decided by the creator of the report.

The array order of these information is expected to be consited for laboratory reports that comply with the HL7 Europe Laboratory Report IG.

The persistence layer SHALL also keep the provided array element order as standard sorting for laboratory reports in their system.

Users MAY also sort the data interactively in their system in other ways, provided the system offers such functions.

Usages:

- Use this Profile: Bundle: Laboratory Report
- Examples for this Profile: DiagnosticReport/dr-lab-example

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 |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 1..1 | (Complex) | Associated Lab Report Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition Constraints: ext-1
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
extension:note |  | 0..* | (Complex) | R5: Comments about the diagnostic report (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note Constraints: ext-1
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | 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 | Report Category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code | Σ | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered).
Slices for effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report. Slice: Unordered, Open by type:$this
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Effective period of the report
Slices for performer | Σ | 0..* | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
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
link | Σ | 1..1 | Reference(Media) | Reference to the image or data
Slices for extension |  |  |  | Content/Rules for all slices
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/alternate-reference"
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
display | Σ | 1..1 | string | Text stating use of cross-version extension 'link'
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std.
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReportEuCore

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:DiagnosticReportCompositionR5 |  | 1..1 | R5 DiagnosticReport.composition | Associated Lab Report Composition
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
identifier |  | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | What was requested
Slices for category |  | 0..* | CodeableConcept | Report Category Slice: Unordered, Open by value:$this
category:studyType |  | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty |  | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code |  | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
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 Laboratory Report is about (when test ordered).
specimen |  | 0..* | Reference(Specimen: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
imagingStudy |  | 0..0 |  | Study subject to this report
media |  | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
link |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..0 |  | Logical reference, when literal reference is not known
display |  | 1..1 | string | Text stating use of cross-version extension 'link'
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
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 diagnostic report content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 1..1 | (Complex) | Associated Lab Report Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition Constraints: ext-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
extension:note |  | 0..* | (Complex) | R5: Comments about the diagnostic report (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note Constraints: ext-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 0..1 | Annotation | Comments about the diagnostic report
id |  | 0..1 | string | 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: Hl7VSCommentType (3.0.0) (example)
author[x] | Σ | 0..1 |  | Individual responsible for the annotation
authorReference |  |  | Reference(Practitioner | 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 | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | 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 | Report Category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code | Σ | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered).
Slices for effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report. Slice: Unordered, Open by type:$this
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Effective period of the report
issued | Σ | 0..1 | instant | Date and time this report was issued
Slices for performer | Σ | 0..* | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
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(Media) | Reference to the image or data
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
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/alternate-reference"
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
display | Σ | 1..1 | string | Text stating use of cross-version extension 'link'
conclusion |  | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📍3.0.0 | THO v7.1
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std.
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReportEuCore

Summary

Mandatory: 2 elements(1 nested mandatory element)
Prohibited: 4 elements

Structures

This structure refers to these other structures:

- Composition: Laboratory Report (http://hl7.eu/fhir/laboratory/StructureDefinition/Composition-eu-lab)
- ServiceRequest: Laboratory Order (http://hl7.eu/fhir/laboratory/StructureDefinition/ServiceRequest-eu-lab)
- Specimen: Laboratory (http://hl7.eu/fhir/laboratory/StructureDefinition/Specimen-eu-lab)
- Observation Results: laboratory (http://hl7.eu/fhir/laboratory/StructureDefinition/Observation-resultslab-eu-lab)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/alternate-reference

Slices

This structure defines the following Slices:

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

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 1..1 | (Complex) | Associated Lab Report Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition Constraints: ext-1
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
extension:note |  | 0..* | (Complex) | R5: Comments about the diagnostic report (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note Constraints: ext-1
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | 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 | Report Category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code | Σ | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered).
Slices for effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report. Slice: Unordered, Open by type:$this
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Effective period of the report
Slices for performer | Σ | 0..* | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
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
link | Σ | 1..1 | Reference(Media) | Reference to the image or data
Slices for extension |  |  |  | Content/Rules for all slices
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/alternate-reference"
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
display | Σ | 1..1 | string | Text stating use of cross-version extension 'link'
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std.
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from DiagnosticReportEuCore

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:DiagnosticReportCompositionR5 |  | 1..1 | R5 DiagnosticReport.composition | Associated Lab Report Composition
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
identifier |  | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | What was requested
Slices for category |  | 0..* | CodeableConcept | Report Category Slice: Unordered, Open by value:$this
category:studyType |  | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty |  | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code |  | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
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 Laboratory Report is about (when test ordered).
specimen |  | 0..* | Reference(Specimen: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
imagingStudy |  | 0..0 |  | Study subject to this report
media |  | 0..* | BackboneElement | Additional data (like images, diagrams or documents) associated with this report
link |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..0 |  | Logical reference, when literal reference is not known
display |  | 1..1 | string | Text stating use of cross-version extension 'link'
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReportEuCore | Laboratory Report DiagnosticReport
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 diagnostic report content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:DiagnosticReportCompositionR5 |  | 1..1 | (Complex) | Associated Lab Report Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition Constraints: ext-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
value[x] |  | 1..1 | Reference(Composition: Laboratory Report) | Reference to a Composition resource for the DiagnosticReport structure
extension:note |  | 0..* | (Complex) | R5: Comments about the diagnostic report (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note Constraints: ext-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url Constraints: ext-1
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"
value[x] |  | 0..1 | Annotation | Comments about the diagnostic report
id |  | 0..1 | string | 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: Hl7VSCommentType (3.0.0) (example)
author[x] | Σ | 0..1 |  | Individual responsible for the annotation
authorReference |  |  | Reference(Practitioner | 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 | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest: Laboratory Order) | 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 | Report Category Slice: Unordered, Open by value:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required)
category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required)
code | Σ | 1..1 | CodeableConcept | Type of (Laboratory) Report Binding: Laboratory Report Types (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core) | Patient: Animal (EU core) | Group | Location | Device) | Who and/or what this report is about
encounter | Σ | 0..1 | Reference(Encounter) | The healthcare event which this Laboratory Report is about (when test ordered).
Slices for effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report. Slice: Unordered, Open by type:$this
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Effective period of the report
issued | Σ | 0..1 | instant | Date and time this report was issued
Slices for performer | Σ | 0..* | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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(PractitionerRole (EU core) | Practitioner (EU core) | Organization (EU core) | 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: Laboratory) | Specimens this report is based on.
result |  | 0..* | Reference(Observation Results: laboratory) | results
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(Media) | Reference to the image or data
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:link |  | 0..1 | (Complex) | DocumentReference containing additional information/attachments URL: http://hl7.org/fhir/StructureDefinition/alternate-reference
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/alternate-reference"
value[x] |  | 1..1 | Reference(DocumentReference) | Value of extension
display | Σ | 1..1 | string | Text stating use of cross-version extension 'link'
conclusion |  | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm |  | 0..* | Attachment | Entire report as issued (pdf recommended)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DiagnosticReport.extension:note.​value[x].extension:annotation-type.​value[x] | Base | example | hl7VS-commentType | 📍3.0.0 | THO v7.1
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std.
DiagnosticReport.category:studyType | Base | required | Laboratory Study Types | 📦2.0.0 | This IG
DiagnosticReport.category:specialty | Base | required | Laboratory Specialty | 📦2.0.0 | This IG
DiagnosticReport.code | Base | preferred | Laboratory Report Types | 📦2.0.0 | This IG
DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReportEuCore

Summary

Mandatory: 2 elements(1 nested mandatory element)
Prohibited: 4 elements

Structures

This structure refers to these other structures:

- Composition: Laboratory Report (http://hl7.eu/fhir/laboratory/StructureDefinition/Composition-eu-lab)
- ServiceRequest: Laboratory Order (http://hl7.eu/fhir/laboratory/StructureDefinition/ServiceRequest-eu-lab)
- Specimen: Laboratory (http://hl7.eu/fhir/laboratory/StructureDefinition/Specimen-eu-lab)
- Observation Results: laboratory (http://hl7.eu/fhir/laboratory/StructureDefinition/Observation-resultslab-eu-lab)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/alternate-reference

Slices

This structure defines the following Slices:

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

Maturity: 2

Other representations of profile: CSV, Excel, Schematron