{ "resourceType": "StructureDefinition", "id": "AIReport", "url": "https://medavis.com/fhir/StructureDefinition/AIReport", "version": "0.1", "name": "AIReport", "title": "AI Report", "status": "draft", "publisher": "medavis GmbH", "contact": [ { "name": "Steffen Eitelmann", "telecom": [ { "system": "email", "value": "steffen.eitelmann@medavis.com", "use": "work" } ] } ], "description": "AI report containing results from AI systems as DiagnosticReport for reporting systems", "copyright": "medavis GmbH", "fhirVersion": "5.0.0", "kind": "resource", "abstract": false, "type": "DiagnosticReport", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "derivation": "constraint", "snapshot": { "element": [ { "id": "DiagnosticReport", "path": "DiagnosticReport", "short": "A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports", "definition": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, products, substances, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. The report also includes non-clinical context such as batch analysis and stability reporting of products and substances.", "comment": "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.", "alias": [ "Report", "Test", "Result", "Results", "Labs", "Laboratory" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "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", "expression": "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()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "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." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dgr-1", "severity": "error", "human": "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`", "expression": "composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))", "source": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport" } ], "mustSupport": false, "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "Entity, Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "w5", "map": "clinical.diagnostics" }, { "identity": "v2", "map": "ORU -> OBR" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.id", "path": "DiagnosticReport.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mustSupport": false, "isModifier": false, "isSummary": true }, { "id": "DiagnosticReport.meta", "path": "DiagnosticReport.meta", "short": "Metadata about the resource", "definition": "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.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.implicitRules", "path": "DiagnosticReport.implicitRules", "short": "A set of rules under which this content was created", "definition": "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.", "comment": "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 its narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.language", "path": "DiagnosticReport.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "required", "description": "IETF language tag for a human language", "valueSet": "http://hl7.org/fhir/ValueSet/all-languages|5.0.0", "additional": [ { "purpose": "starter", "valueSet": "http://hl7.org/fhir/ValueSet/languages" } ] }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.text", "path": "DiagnosticReport.text", "short": "Text summary of the resource, for human interpretation", "definition": "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.", "comment": "Contained resources do not have a 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.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "dom-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "DiagnosticReport.contained", "path": "DiagnosticReport.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.", "comment": "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "condition": [ "dom-2", "dom-4", "dom-3", "dom-5" ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.extension", "path": "DiagnosticReport.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.modifierExtension", "path": "DiagnosticReport.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.identifier", "path": "DiagnosticReport.identifier", "short": "Business identifier for report", "definition": "Identifiers assigned to this report by the performer or other systems.", "comment": "Usually assigned by the Information System of the diagnostic service provider (filler id).", "requirements": "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.", "alias": [ "ReportID", "Filler ID", "Placer ID" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "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" }, { "identity": "rim", "map": "id" } ] }, { "id": "DiagnosticReport.basedOn", "path": "DiagnosticReport.basedOn", "short": "What was requested", "definition": "Details concerning a service requested.", "comment": "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.", "requirements": "This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.", "alias": [ "Request" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.basedOn", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CarePlan", "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.basedOn" }, { "identity": "v2", "map": "ORC? OBR-2/3?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "DiagnosticReport.status", "path": "DiagnosticReport.status", "short": "registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown", "definition": "The status of the diagnostic report.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "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", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticReportStatus" } ], "strength": "required", "description": "The status of the diagnostic report.", "valueSet": "http://hl7.org/fhir/ValueSet/diagnostic-report-status|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "v2", "map": "OBR-25 (not 1:1 mapping)" }, { "identity": "rim", "map": "statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\"" } ] }, { "id": "DiagnosticReport.category", "path": "DiagnosticReport.category", "short": "Service category", "definition": "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.", "comment": "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.", "alias": [ "Department", "Sub-department", "Service", "Discipline" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Codes for diagnostic service sections." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticServiceSection" } ], "strength": "example", "description": "HL7 V2 table 0074", "valueSet": "http://hl7.org/fhir/ValueSet/diagnostic-service-sections" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "v2", "map": "OBR-24" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code" } ] }, { "id": "DiagnosticReport.code", "path": "DiagnosticReport.code", "short": "Name/Code for this diagnostic report", "definition": "A code or name that describes this diagnostic report.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "Type" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Codes that describe Diagnostic Reports." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticReportCodes" } ], "strength": "preferred", "description": "LOINC Codes for Diagnostic Reports", "valueSet": "http://hl7.org/fhir/ValueSet/report-codes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "v2", "map": "OBR-4 (HL7 V2 doesn't provide an easy way to indicate both the ordered test and the performed panel)" }, { "identity": "rim", "map": "code" } ] }, { "id": "DiagnosticReport.subject", "path": "DiagnosticReport.subject", "short": "The subject of the report - usually, but not always, the patient", "definition": "The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "SHALL know the subject context.", "alias": [ "Patient" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/Medication", "http://hl7.org/fhir/StructureDefinition/Substance", "http://hl7.org/fhir/StructureDefinition/BiologicallyDerivedProduct" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "PID-3 (no HL7 V2 mapping for Group or Device)" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "id": "DiagnosticReport.encounter", "path": "DiagnosticReport.encounter", "short": "Health care event when test ordered", "definition": "The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.", "comment": "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).", "requirements": "Links the request to the Encounter context.", "alias": [ "Context" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.encounter" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.effective[x]", "path": "DiagnosticReport.effective[x]", "short": "Clinically relevant time/time-period for report", "definition": "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.", "comment": "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.", "requirements": "Need to know where in the patient history to file/present this report.", "alias": [ "Observation time", "Effective Time", "Occurrence" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "OBR-7" }, { "identity": "rim", "map": "effectiveTime" } ] }, { "id": "DiagnosticReport.issued", "path": "DiagnosticReport.issued", "short": "DateTime this version was made", "definition": "The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.", "comment": "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.", "requirements": "Clinicians need to be able to check the date that the report was released.", "alias": [ "Date published", "Date Issued", "Date Verified" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.issued", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "v2", "map": "OBR-22" }, { "identity": "rim", "map": "participation[typeCode=VRF or AUT].time" } ] }, { "id": "DiagnosticReport.performer", "path": "DiagnosticReport.performer", "short": "Responsible Diagnostic Service", "definition": "The diagnostic service that is responsible for issuing the report.", "comment": "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.", "requirements": "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.", "alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company", "Authorized by", "Director" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.performer", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/CareTeam" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.actor" }, { "identity": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": ".participation[typeCode=PRF]" } ] }, { "id": "DiagnosticReport.resultsInterpreter", "path": "DiagnosticReport.resultsInterpreter", "short": "Primary result interpreter", "definition": "The practitioner or organization that is responsible for the report's conclusions and interpretations.", "comment": "Might not be the same entity that takes responsibility for the clinical report.", "requirements": "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.", "alias": [ "Analyzed by", "Reported by" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.resultsInterpreter", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/CareTeam" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.actor" }, { "identity": "v2", "map": "OBR-32, PRT-8 (where this PRT-4-Participation = \"PI\")" }, { "identity": "rim", "map": ".participation[typeCode=PRF]" } ] }, { "id": "DiagnosticReport.specimen", "path": "DiagnosticReport.specimen", "short": "Specimens this report is based on", "definition": "Details about the specimens on which this diagnostic report is based.", "comment": "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.", "requirements": "Need to be able to report information about the collected specimens on which the report is based.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.specimen", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Specimen" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "id": "DiagnosticReport.result", "path": "DiagnosticReport.result", "short": "Observations", "definition": "[Observations](observation.html) that are part of this diagnostic report.", "comment": "Observations can contain observations.", "requirements": "Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.", "alias": [ "Data", "Atomic Value", "Result", "Atomic result", "Data", "Test", "Analyte", "Battery", "Organizer" ], "min": 1, "max": "*", "base": { "path": "DiagnosticReport.result", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": [ "https://medavis.com/fhir/StructureDefinition/AIResult" ], "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ] } ], "condition": [ "dgr-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "OBXs" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "id": "DiagnosticReport.result.id", "path": "DiagnosticReport.result.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mustSupport": false, "isModifier": false, "isSummary": true }, { "id": "DiagnosticReport.result.meta", "path": "DiagnosticReport.result.meta", "short": "Metadata about the resource", "definition": "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.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.implicitRules", "path": "DiagnosticReport.result.implicitRules", "short": "A set of rules under which this content was created", "definition": "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.", "comment": "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 its narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.language", "path": "DiagnosticReport.result.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "required", "description": "IETF language tag for a human language", "valueSet": "http://hl7.org/fhir/ValueSet/all-languages|5.0.0", "additional": [ { "purpose": "starter", "valueSet": "http://hl7.org/fhir/ValueSet/languages" } ] }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.text", "path": "DiagnosticReport.result.text", "short": "Text summary of the resource, for human interpretation", "definition": "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.", "comment": "Contained resources do not have a 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.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "dom-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "DiagnosticReport.result.contained", "path": "DiagnosticReport.result.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.", "comment": "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "condition": [ "dom-2", "dom-4", "dom-3", "dom-5" ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.extension", "path": "DiagnosticReport.result.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.modifierExtension", "path": "DiagnosticReport.result.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.identifier", "path": "DiagnosticReport.result.identifier", "short": "Business Identifier for observation", "definition": "A unique identifier assigned to this observation.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows observations to be distinguished and referenced.", "min": 1, "max": "*", "base": { "path": "Observation.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "OBX-21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 3) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4." }, { "identity": "rim", "map": "id" } ] }, { "id": "DiagnosticReport.result.identifier.id", "path": "DiagnosticReport.result.identifier.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.identifier.extension", "path": "DiagnosticReport.result.identifier.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.identifier.use", "path": "DiagnosticReport.result.identifier.use", "short": "usual | official | temp | secondary | old (If known)", "definition": "The purpose of this identifier.", "comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Identifies the purpose for this identifier, if known ." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierUse" } ], "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DiagnosticReport.result.identifier.type", "path": "DiagnosticReport.result.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 0, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierType" } ], "strength": "extensible", "description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DiagnosticReport.result.identifier.system", "path": "DiagnosticReport.result.identifier.system", "short": "The namespace for the identifier value", "definition": "Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique.", "comment": "Identifier.system is always case sensitive.", "requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.", "min": 1, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "example": [ { "label": "General", "valueUri": "http://www.acme.com/identifiers/patient" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "id": "DiagnosticReport.result.identifier.value", "path": "DiagnosticReport.result.identifier.value", "short": "The value that is unique", "definition": "The portion of the identifier typically relevant to the user and which is unique within the context of the system.", "comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [http://hl7.org/fhir/StructureDefinition/rendered-value](http://hl7.org/fhir/extensions/StructureDefinition-rendered-value.html)). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.", "min": 1, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "123456" } ], "condition": [ "ident-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "id": "DiagnosticReport.result.identifier.period", "path": "DiagnosticReport.result.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "id": "DiagnosticReport.result.identifier.assigner", "path": "DiagnosticReport.result.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.", "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "id": "DiagnosticReport.result.instantiates[x]", "path": "DiagnosticReport.result.instantiates[x]", "short": "Instantiates FHIR ObservationDefinition", "definition": "The reference to a FHIR ObservationDefinition resource that provides the definition that is adhered to in whole or in part by this Observation instance.", "comment": "ObservationDefinition can be referenced by its canonical url using instantiatesCanonical, or by a name or an identifier using the appropriate sub-elements of instantiatesReference.", "min": 0, "max": "1", "base": { "path": "Observation.instantiates[x]", "min": 0, "max": "1" }, "type": [ { "code": "canonical", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ObservationDefinition" ] }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ObservationDefinition" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.instantiatesCanonical" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=DEFN].target" } ] }, { "id": "DiagnosticReport.result.basedOn", "path": "DiagnosticReport.result.basedOn", "short": "Fulfills plan, proposal or order", "definition": "A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.", "alias": [ "Fulfills" ], "min": 0, "max": "*", "base": { "path": "Observation.basedOn", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CarePlan", "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.basedOn" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[moodCode=EVN]" } ] }, { "id": "DiagnosticReport.result.triggeredBy", "path": "DiagnosticReport.result.triggeredBy", "short": "Triggering observation(s)", "definition": "Identifies the observation(s) that triggered the performance of this observation.", "min": 0, "max": "*", "base": { "path": "Observation.triggeredBy", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[moodCode=EVN]" } ] }, { "id": "DiagnosticReport.result.triggeredBy.id", "path": "DiagnosticReport.result.triggeredBy.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.triggeredBy.extension", "path": "DiagnosticReport.result.triggeredBy.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.triggeredBy.modifierExtension", "path": "DiagnosticReport.result.triggeredBy.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.triggeredBy.observation", "path": "DiagnosticReport.result.triggeredBy.observation", "short": "Triggering observation", "definition": "Reference to the triggering observation.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 1, "max": "1", "base": { "path": "Observation.triggeredBy.observation", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "rim", "map": "outBoundRelationship" } ] }, { "id": "DiagnosticReport.result.triggeredBy.type", "path": "DiagnosticReport.result.triggeredBy.type", "short": "reflex | repeat | re-run", "definition": "The type of trigger.\nReflex | Repeat | Re-run.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "min": 1, "max": "1", "base": { "path": "Observation.triggeredBy.type", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "TriggeredByType" } ], "strength": "required", "description": "The type of TriggeredBy Observation.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-triggeredbytype|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "code" } ] }, { "id": "DiagnosticReport.result.triggeredBy.reason", "path": "DiagnosticReport.result.triggeredBy.reason", "short": "Reason that the observation was triggered", "definition": "Provides the reason why this observation was performed as a result of the observation(s) referenced.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "min": 0, "max": "1", "base": { "path": "Observation.triggeredBy.reason", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "annotation" } ] }, { "id": "DiagnosticReport.result.partOf", "path": "DiagnosticReport.result.partOf", "short": "Part of referenced event", "definition": "A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.", "comment": "To link an Observation to an Encounter use `encounter`. See the [Notes](observation.html#obsgrouping) below for guidance on referencing another Observation.", "alias": [ "Container" ], "min": 0, "max": "*", "base": { "path": "Observation.partOf", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationAdministration", "http://hl7.org/fhir/StructureDefinition/MedicationDispense", "http://hl7.org/fhir/StructureDefinition/MedicationStatement", "http://hl7.org/fhir/StructureDefinition/Procedure", "http://hl7.org/fhir/StructureDefinition/Immunization", "http://hl7.org/fhir/StructureDefinition/ImagingStudy", "http://hl7.org/fhir/StructureDefinition/GenomicStudy" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.partOf" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "DiagnosticReport.result.status", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "path": "DiagnosticReport.result.status", "label": "status", "short": "registered | preliminary | final | amended +", "definition": "The status of the result value.", "comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.", "requirements": "Need to track the status of individual results. Some results are finalized before the whole report is finalized.", "min": 1, "max": "1", "base": { "path": "Observation.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "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", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationStatus" } ], "strength": "required", "description": "Codes providing the status of an observation.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-status|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "sct-concept", "map": "< 445584004 |Report by finality status|" }, { "identity": "v2", "map": "OBX-11" }, { "identity": "rim", "map": "status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of \"revise\"" } ] }, { "id": "DiagnosticReport.result.category", "path": "DiagnosticReport.result.category", "short": "Classification of type of observation", "definition": "A code that classifies the general type of observation being made.", "comment": "In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.", "requirements": "Used for filtering what observations are retrieved and displayed.", "min": 0, "max": "*", "base": { "path": "Observation.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "strength": "preferred", "description": "Codes for high level observation categories.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-category" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" } ] }, { "id": "DiagnosticReport.result.code", "path": "DiagnosticReport.result.code", "short": "Type of observation (code / type)", "definition": "Describes what was observed. Sometimes this is called the observation \"name\".", "comment": "*All* code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.", "requirements": "Knowing what kind of observation is being made is essential to understanding the observation.", "alias": [ "Name" ], "min": 1, "max": "1", "base": { "path": "Observation.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "example": [ { "label": "Snomed", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "125605004", "display": "Fracture of bone" } ] } } ], "condition": [ "obs-7" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCode" } ], "strength": "example", "description": "Codes identifying names of simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-codes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR < 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" }, { "identity": "sct-attr", "map": "116680003 |Is a|" } ] }, { "id": "DiagnosticReport.result.subject", "path": "DiagnosticReport.result.subject", "short": "Who and/or what the observation is about", "definition": "The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about and into whose or what record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the `focus` element or the `code` itself specifies the actual focus of the observation.", "comment": "One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. The subject of an Observation may in some cases be a procedure. This supports the regulatory inspection use case where observations are captured during inspections of a procedure that is being performed (independent of any particular patient or whether patient related at all).", "requirements": "Observations have no value if you don't know who or what they're about.", "min": 0, "max": "1", "base": { "path": "Observation.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Procedure", "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/Medication", "http://hl7.org/fhir/StructureDefinition/Substance", "http://hl7.org/fhir/StructureDefinition/BiologicallyDerivedProduct", "http://hl7.org/fhir/StructureDefinition/NutritionProduct" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": "participation[typeCode=RTGT]" } ] }, { "id": "DiagnosticReport.result.focus", "path": "DiagnosticReport.result.focus", "short": "What the observation is about, when it is not about the subject of record", "definition": "The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus.", "comment": "Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., \"Blood Glucose\") and does not need to be represented separately using this element. Use `specimen` if a reference to a specimen is required. If a code is required instead of a resource use either `bodysite` for bodysites or the standard extension [http://hl7.org/fhir/StructureDefinition/observation-focusCode](http://hl7.org/fhir/extensions/StructureDefinition-observation-focusCode.html).", "min": 0, "max": "*", "base": { "path": "Observation.focus", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "id": "DiagnosticReport.result.encounter", "path": "DiagnosticReport.result.encounter", "short": "Healthcare event during which this observation is made", "definition": "The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.", "comment": "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).", "requirements": "For some observations it may be important to know the link between an observation and a particular encounter.", "alias": [ "Context" ], "min": 0, "max": "1", "base": { "path": "Observation.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.encounter" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "v2", "map": "PV1" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.result.effective[x]", "path": "DiagnosticReport.result.effective[x]", "short": "Clinically relevant time/time-period for observation", "definition": "The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the \"physiologically relevant time\". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.", "comment": "At least a date should be present unless this observation is a historical report. For recording imprecise or \"fuzzy\" times (For example, a blood glucose measurement taken \"after breakfast\") use the [Timing](datatypes.html#timing) datatype which allow the measurement to be tied to regular life events.", "requirements": "Knowing when an observation was deemed true is important to its relevance as well as determining trends.", "alias": [ "Occurrence" ], "min": 0, "max": "1", "base": { "path": "Observation.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" }, { "code": "Timing" }, { "code": "instant" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)" }, { "identity": "rim", "map": "effectiveTime" } ] }, { "id": "DiagnosticReport.result.issued", "path": "DiagnosticReport.result.issued", "short": "Date/Time this version was made available", "definition": "The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified.", "comment": "For Observations that don't require review and verification, it may be the same as the [`lastUpdated` ](resource-definitions.html#Meta.lastUpdated) time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the `lastUpdated` time of the resource itself due to a non-clinically significant update that doesn't require the new version to be reviewed and verified again.", "min": 0, "max": "1", "base": { "path": "Observation.issued", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "v2", "map": "OBR-22 (or MSH-7), or perhaps OBX-19 (depends on who observation made)" }, { "identity": "rim", "map": "participation[typeCode=AUT].time" } ] }, { "id": "DiagnosticReport.result.performer", "path": "DiagnosticReport.result.performer", "short": "Who is responsible for the observation", "definition": "Who was responsible for asserting the observed value as \"true\".", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.", "min": 0, "max": "*", "base": { "path": "Observation.performer", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/CareTeam", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.actor" }, { "identity": "v2", "map": "OBX-15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO'" }, { "identity": "rim", "map": "participation[typeCode=PRF]" } ] }, { "id": "DiagnosticReport.result.value[x]", "path": "DiagnosticReport.result.value[x]", "short": "Actual result", "definition": "The information determined as a result of making the observation, if the information has a simple value. Example currently supported Strings: \"FINDING\", \"NO FINDING\", \"DOUBT\"", "comment": "- An observation may have:\n 1. a single value here\n 1. both a value and a set of related or component values\n 1. only a set of related or component values.\n- If a value is present, the datatype for this element should be determined by the `code`.\n- *CodeableConcept* with just a text would be used instead of a string if the field was usually coded, or if the type associated with the `code` defines a coded value.\n- *Attachment* is used if the observation result value is a binary file such as an image. If the observation result value is derived from the binary file (for example 'X' detected and here is the the proof in this image), the binary file may be directly represented using *DocumentReference* and referenced by `derivedFrom`.\n- The usage of valueReference is restricted to the MolecularSequence resource when used as a definitional resource, not as a patient-specific finding. .\n- For additional guidance, see the [Notes section](observation.html#notes) below.", "requirements": "An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.", "min": 1, "max": "1", "base": { "path": "Observation.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" } ], "condition": [ "obs-7", "obs-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "< 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX-2, OBX-5, OBX-6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "DiagnosticReport.result.dataAbsentReason", "path": "DiagnosticReport.result.dataAbsentReason", "short": "Why the result is missing", "definition": "Provides a reason why the expected value in the element Observation.value[x] is missing.", "comment": "Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be \"detected\", \"not detected\", \"inconclusive\", or \"specimen unsatisfactory\". \n\nThe alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code \"error\" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "1", "base": { "path": "Observation.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "DiagnosticReport.result.interpretation", "path": "DiagnosticReport.result.interpretation", "short": "Priority, Alert and FindingFlag", "definition": "Contains Priority of the result (PH, PM, PL, PN) and/or an Alert indicator (A, N, NA)", "comment": "Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.", "requirements": "For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.", "alias": [ "Abnormal Flag" ], "min": 1, "max": "*", "base": { "path": "Observation.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "example": [ { "label": "Priority", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/flag-priority-code", "code": "PH", "display": "High Priority" } ] } }, { "label": "Alarm", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "A", "display": "Alarm" } ] } } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "DiagnosticReport.result.note", "path": "DiagnosticReport.result.note", "short": "Comments about the observation", "definition": "Comments about the observation or the results.", "comment": "May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.", "requirements": "Need to be able to provide free text additional information.", "min": 0, "max": "*", "base": { "path": "Observation.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Act" }, { "identity": "v2", "map": "NTE-3 (partner NTE to OBX, or sometimes another (child?) OBX)" }, { "identity": "rim", "map": "subjectOf.observationEvent[code=\"annotation\"].value" } ] }, { "id": "DiagnosticReport.result.bodySite", "path": "DiagnosticReport.result.bodySite", "short": "Observed body part", "definition": "Indicates the site on the subject's body where the observation was made (i.e. the target site).", "comment": "Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component.", "min": 0, "max": "1", "base": { "path": "Observation.bodySite", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-8" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Codes describing anatomical locations. May include laterality." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BodySite" } ], "strength": "example", "description": "SNOMED CT Body site concepts", "valueSet": "http://hl7.org/fhir/ValueSet/body-site" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 123037004 |Body structure|" }, { "identity": "v2", "map": "OBX-20" }, { "identity": "rim", "map": "targetSiteCode" }, { "identity": "sct-attr", "map": "718497002 |Inherent location|" } ] }, { "id": "DiagnosticReport.result.bodyStructure", "path": "DiagnosticReport.result.bodyStructure", "short": "Observed body structure", "definition": "Indicates the body structure on the subject's body where the observation was made (i.e. the target site).", "comment": "Only used if not implicit in code found in Observation.code or bodySite is used. In many systems, this may be represented as a related observation instead of an inline component.", "min": 0, "max": "1", "base": { "path": "Observation.bodyStructure", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/BodyStructure" ] } ], "condition": [ "obs-8" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "rim", "map": "targetSiteCode" } ] }, { "id": "DiagnosticReport.result.method", "path": "DiagnosticReport.result.method", "short": "How it was done", "definition": "Indicates the mechanism used to perform the observation.", "comment": "Only used if not implicit in code for Observation.code.", "requirements": "In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.", "min": 0, "max": "1", "base": { "path": "Observation.method", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationMethod" } ], "strength": "example", "description": "Methods for simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-methods" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX-17" }, { "identity": "rim", "map": "methodCode" } ] }, { "id": "DiagnosticReport.result.specimen", "path": "DiagnosticReport.result.specimen", "short": "Specimen used for this observation", "definition": "The specimen that was used when this observation was made.", "comment": "Should only be used if not implicit in code found in `Observation.code`. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).", "min": 0, "max": "1", "base": { "path": "Observation.specimen", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Specimen", "http://hl7.org/fhir/StructureDefinition/Group" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "obs-9", "severity": "error", "human": "If Observation.specimen is a reference to Group, the group can only have specimens", "expression": "(reference.resolve().exists() and reference.resolve() is Group) implies reference.resolve().member.entity.resolve().all($this is Specimen)", "source": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 123038009 |Specimen|" }, { "identity": "v2", "map": "SPM segment" }, { "identity": "rim", "map": "participation[typeCode=SPC].specimen" }, { "identity": "sct-attr", "map": "704319004 |Inherent in|" } ] }, { "id": "DiagnosticReport.result.device", "path": "DiagnosticReport.result.device", "short": "A reference to the device that generates the measurements or the device settings for the device", "definition": "A reference to the device that generates the measurements or the device settings for the device.", "comment": "Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.", "min": 0, "max": "1", "base": { "path": "Observation.device", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/DeviceMetric" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 49062001 |Device|" }, { "identity": "v2", "map": "OBX-17 / PRT -10" }, { "identity": "rim", "map": "participation[typeCode=DEV]" }, { "identity": "sct-attr", "map": "424226004 |Using device|" } ] }, { "id": "DiagnosticReport.result.referenceRange", "path": "DiagnosticReport.result.referenceRange", "short": "Provides guide for interpretation", "definition": "Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an \"OR\". In other words, to represent two distinct target populations, two `referenceRange` elements would be used.", "comment": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "Knowing what values are considered \"normal\" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "obs-3", "severity": "error", "human": "Must have at least a low or a high or text", "expression": "low.exists() or high.exists() or text.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.result.referenceRange.id", "path": "DiagnosticReport.result.referenceRange.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.referenceRange.extension", "path": "DiagnosticReport.result.referenceRange.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.referenceRange.modifierExtension", "path": "DiagnosticReport.result.referenceRange.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.referenceRange.low", "path": "DiagnosticReport.result.referenceRange.low", "short": "Low Range, if relevant", "definition": "The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "condition": [ "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.low" } ] }, { "id": "DiagnosticReport.result.referenceRange.high", "path": "DiagnosticReport.result.referenceRange.high", "short": "High Range, if relevant", "definition": "The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3).", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "condition": [ "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.high" } ] }, { "id": "DiagnosticReport.result.referenceRange.normalValue", "path": "DiagnosticReport.result.referenceRange.normalValue", "short": "Normal value, if relevant", "definition": "The value of the normal value of the reference range.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.normalValue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationReferenceRangeNormalValue" } ], "strength": "extensible", "description": "Codes identifying the normal value of the observation.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-referencerange-normalvalue" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.normal" } ] }, { "id": "DiagnosticReport.result.referenceRange.type", "path": "DiagnosticReport.result.referenceRange.type", "short": "Reference range qualifier", "definition": "Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range.", "comment": "This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.", "requirements": "Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeMeaning" } ], "strength": "preferred", "description": "Code for the meaning of a reference range.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-meaning" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "DiagnosticReport.result.referenceRange.appliesTo", "path": "DiagnosticReport.result.referenceRange.appliesTo", "short": "Reference range population", "definition": "Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple `appliesTo` are interpreted as an \"AND\" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used.", "comment": "This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.", "requirements": "Need to be able to identify the target population for proper interpretation.", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange.appliesTo", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeType" } ], "strength": "example", "description": "Codes identifying the population the reference range applies to.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-appliesto" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "DiagnosticReport.result.referenceRange.age", "path": "DiagnosticReport.result.referenceRange.age", "short": "Applicable age range, if relevant", "definition": "The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.", "comment": "The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.", "requirements": "Some analytes vary greatly over age.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.age", "min": 0, "max": "1" }, "type": [ { "code": "Range" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "rng-2", "severity": "error", "human": "If present, low SHALL have a lower value than high", "expression": "low.value.empty() or high.value.empty() or low.lowBoundary().comparable(high.highBoundary()).not() or (low.lowBoundary() <= high.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Range" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "NR and also possibly SN (but see also quantity)" }, { "identity": "rim", "map": "IVL [lowClosed=\"true\" and highClosed=\"true\"]or URG" }, { "identity": "rim", "map": "outboundRelationship[typeCode=PRCN].targetObservationCriterion[code=\"age\"].value" } ] }, { "id": "DiagnosticReport.result.referenceRange.text", "path": "DiagnosticReport.result.referenceRange.text", "short": "Text based reference range in an observation", "definition": "Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of \"Negative\" or a list or table of \"normals\".", "comment": "Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.text", "min": 0, "max": "1" }, "type": [ { "code": "markdown" } ], "condition": [ "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:ST" } ] }, { "id": "DiagnosticReport.result.hasMember", "path": "DiagnosticReport.result.hasMember", "short": "Related resource that belongs to the Observation group", "definition": "This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.", "comment": "When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see [Notes](observation.html#obsgrouping) below. Note that a system may calculate results from [QuestionnaireResponse](questionnaireresponse.html) into a final score and represent the score as an Observation.", "min": 0, "max": "*", "base": { "path": "Observation.hasMember", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": "outBoundRelationship" } ] }, { "id": "DiagnosticReport.result.derivedFrom", "path": "DiagnosticReport.result.derivedFrom", "short": "Related resource from which the observation is made", "definition": "The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.", "comment": "All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see [Notes](observation.html#obsgrouping) below.", "min": 0, "max": "*", "base": { "path": "Observation.derivedFrom", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/ImagingStudy", "http://hl7.org/fhir/StructureDefinition/ImagingSelection", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/MolecularSequence", "http://hl7.org/fhir/StructureDefinition/GenomicStudy" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": ".targetObservation" } ] }, { "id": "DiagnosticReport.result.component", "path": "DiagnosticReport.result.component", "short": "Component results", "definition": "Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.", "comment": "For a discussion on the ways Observations can be assembled in groups together see [Notes](observation.html#notes) below.", "requirements": "Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.", "min": 0, "max": "*", "base": { "path": "Observation.component", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "obs-7" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "containment by OBX-4?" }, { "identity": "rim", "map": "outBoundRelationship[typeCode=COMP]" } ] }, { "id": "DiagnosticReport.result.component.id", "path": "DiagnosticReport.result.component.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.result.component.extension", "path": "DiagnosticReport.result.component.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.component.modifierExtension", "path": "DiagnosticReport.result.component.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.result.component.code", "path": "DiagnosticReport.result.component.code", "short": "Type of component observation (code / type)", "definition": "Describes what was observed. Sometimes this is called the observation \"code\".", "comment": "*All* code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.", "requirements": "Knowing what kind of observation is being made is essential to understanding the observation.", "min": 1, "max": "1", "base": { "path": "Observation.component.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-7" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCode" } ], "strength": "example", "description": "Codes identifying names of simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-codes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR \r< 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" } ] }, { "id": "DiagnosticReport.result.component.value[x]", "path": "DiagnosticReport.result.component.value[x]", "short": "Actual component result", "definition": "The information determined as a result of making the observation, if the information has a simple value.", "comment": "Used when observation has a set of component observations:\n- An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). \n- If a value is present, the datatype for this element should be determined by the `code`.\n- *CodeableConcept* with just a text would be used instead of a string if the field was usually coded, or if the type associated with the `code` defines a coded value.\n- *Attachment* is used if the observation result value is a binary file such as an image. If the observation result value is derived from the binary file (for example 'X' detected and here is the the proof in this image), the binary file may be directly represented using *DocumentReference* and referenced by `derivedFrom`.\n- If a value is present, the datatype for this element should be determined by the `code`.\n- *CodeableConcept* with just a text would be used instead of a string if the field was usually coded, or if the type associated with the `code` defines a coded value.\n- *Attachment* is used if the observation result value is a binary file such as an image. If the observation result value is derived from the binary file (for example 'X' detected and here is the the proof in this image), the binary file may be directly represented using *DocumentReference* and referenced by `derivedFrom`.\n- The usage of valueReference is restricted to the MolecularSequence resource when used as a definitional resource, not as a patient-specific finding. .\n- For additional guidance, see the [Notes section](observation.html#notes) below.", "requirements": "An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.", "min": 0, "max": "1", "base": { "path": "Observation.component.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "boolean" }, { "code": "integer" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" }, { "code": "Attachment" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "363714003 |Interprets| < 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX-2, OBX-5, OBX-6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "DiagnosticReport.result.component.dataAbsentReason", "path": "DiagnosticReport.result.component.dataAbsentReason", "short": "Why the component result is missing", "definition": "Provides a reason why the expected value in the element Observation.component.value[x] is missing.", "comment": "\"Null\" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be \"detected\", \"not detected\", \"inconclusive\", or \"test not done\". \n\nThe alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code \"error\" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "1", "base": { "path": "Observation.component.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "DiagnosticReport.result.component.interpretation", "path": "DiagnosticReport.result.component.interpretation", "short": "High, low, normal, etc", "definition": "A categorical assessment of an observation value. For example, high, low, normal.", "comment": "Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.", "requirements": "For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.", "alias": [ "Abnormal Flag" ], "min": 0, "max": "*", "base": { "path": "Observation.component.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "DiagnosticReport.result.component.referenceRange", "path": "DiagnosticReport.result.component.referenceRange", "short": "Provides guide for interpretation of component result", "definition": "Guidance on how to interpret the value by comparison to a normal or recommended range.", "comment": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "Knowing what values are considered \"normal\" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.", "min": 0, "max": "*", "base": { "path": "Observation.component.referenceRange", "min": 0, "max": "*" }, "contentReference": "#Observation.referenceRange", "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.result.reference", "path": "DiagnosticReport.result.reference", "min": 1, "base": { "path": "DiagnosticReport.result.reference", "min": 1 } }, { "id": "DiagnosticReport.note", "path": "DiagnosticReport.note", "short": "Comments about the diagnostic report", "definition": "Comments about the diagnostic report.", "comment": "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.", "requirements": "Need to be able to provide free text additional information.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Act" }, { "identity": "rim", "map": "unknown" } ] }, { "id": "DiagnosticReport.study", "path": "DiagnosticReport.study", "short": "Reference to full details of an analysis associated with the diagnostic report", "definition": "One or more links to full details of any study performed during the diagnostic investigation. An ImagingStudy might comprise a set of radiologic images obtained via a procedure that are analyzed as a group. 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. A GenomicStudy might comprise one or more analyses, each serving a specific purpose. These analyses may vary in method (e.g., karyotyping, CNV, or SNV detection), performer, software, devices used, or regions targeted.", "comment": "For laboratory-type studies like GenomeStudy, type resources will be used for tracking additional metadata and workflow aspects of complex studies. ImagingStudy and the media element are somewhat overlapping - typically, the list of image references in the media 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.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.study", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/GenomicStudy", "http://hl7.org/fhir/StructureDefinition/ImagingStudy" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "DiagnosticReport.study.id", "path": "DiagnosticReport.study.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.study.extension", "path": "DiagnosticReport.study.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.study.reference", "path": "DiagnosticReport.study.reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.", "comment": "Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure \"[type]/[id]\" then it should be assumed that the reference is to a FHIR RESTful server.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-2", "ref-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.study.type", "path": "DiagnosticReport.study.type", "short": "Type the reference refers to (e.g. \"Patient\") - must be a resource in resources", "definition": "The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "comment": "This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a known RESTful URL) or by resolving the target of the reference.", "min": 0, "max": "1", "base": { "path": "Reference.type", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Aa resource (or, for logical models, the URI of the logical model)." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FHIRResourceTypeExt" } ], "strength": "extensible", "description": "Aa resource (or, for logical models, the URI of the logical model).", "valueSet": "http://hl7.org/fhir/ValueSet/resource-types" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.study.identifier", "path": "DiagnosticReport.study.identifier", "short": "Logical reference, when literal reference is not known", "definition": "An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.", "comment": "When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).\n\nThis element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.", "min": 1, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "condition": [ "ref-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "rim", "map": ".identifier" } ] }, { "id": "DiagnosticReport.study.identifier.id", "path": "DiagnosticReport.study.identifier.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.study.identifier.extension", "path": "DiagnosticReport.study.identifier.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.study.identifier.use", "path": "DiagnosticReport.study.identifier.use", "short": "usual | official | temp | secondary | old (If known)", "definition": "The purpose of this identifier.", "comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Identifies the purpose for this identifier, if known ." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierUse" } ], "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DiagnosticReport.study.identifier.type", "path": "DiagnosticReport.study.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 0, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierType" } ], "strength": "extensible", "description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DiagnosticReport.study.identifier.system", "path": "DiagnosticReport.study.identifier.system", "short": "The namespace for the identifier value", "definition": "Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique.", "comment": "Identifier.system is always case sensitive.", "requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.", "min": 1, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "fixedUri": "urn:dicom:uid", "example": [ { "label": "General", "valueUri": "http://www.acme.com/identifiers/patient" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "id": "DiagnosticReport.study.identifier.value", "path": "DiagnosticReport.study.identifier.value", "short": "The study instance UID", "definition": "The study instance UID with urn:oid: prefix, for example: urn:oid:1.2.276.0.37.1.337.201501.1.123", "comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [http://hl7.org/fhir/StructureDefinition/rendered-value](http://hl7.org/fhir/extensions/StructureDefinition-rendered-value.html)). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.", "min": 1, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "123456" } ], "condition": [ "ident-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "id": "DiagnosticReport.study.identifier.period", "path": "DiagnosticReport.study.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "id": "DiagnosticReport.study.identifier.assigner", "path": "DiagnosticReport.study.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.", "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "id": "DiagnosticReport.study.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DiagnosticReport.study.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "comment": "This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.supportingInfo", "path": "DiagnosticReport.supportingInfo", "short": "Additional information supporting the diagnostic report", "definition": "This backbone element contains supporting information that was used in the creation of the report not included in the results already included in the report.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.supportingInfo", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.supportingInfo.id", "path": "DiagnosticReport.supportingInfo.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.supportingInfo.extension", "path": "DiagnosticReport.supportingInfo.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.supportingInfo.modifierExtension", "path": "DiagnosticReport.supportingInfo.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.supportingInfo.type", "path": "DiagnosticReport.supportingInfo.type", "short": "Supporting information role code", "definition": "The code value for the role of the supporting information in the diagnostic report.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.supportingInfo.type", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Supporting information role code" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticReportSupportingInfoType" } ], "strength": "example", "description": "The code value for the role of the supporting information in the diagnostic report.", "valueSet": "http://terminology.hl7.org/ValueSet/v2-0936" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "DiagnosticReport.supportingInfo.reference", "path": "DiagnosticReport.supportingInfo.reference", "short": "Supporting information reference", "definition": "The reference for the supporting information in the diagnostic report.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.supportingInfo.reference", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Procedure", "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/Citation" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "DiagnosticReport.media", "path": "DiagnosticReport.media", "short": "Key images or data associated with this report", "definition": "A list of key images or data associated with this report. The images or data are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).", "requirements": "Many diagnostic services include images or data in the report as part of their service.", "alias": [ "DICOM", "Slides", "Scans" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.media", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "id": "DiagnosticReport.media.id", "path": "DiagnosticReport.media.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.media.extension", "path": "DiagnosticReport.media.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "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 managable, 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.media.modifierExtension", "path": "DiagnosticReport.media.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "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 managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "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.", "requirements": "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.media.comment", "path": "DiagnosticReport.media.comment", "short": "Comment about the image or data (e.g. explanation)", "definition": "A comment about the image or data. Typically, this is used to provide an explanation for why the image or data is included, or to draw the viewer's attention to important features.", "comment": "The comment should be displayed with the image or data. It would be common for the report to include additional discussion of the image or data contents or in other sections such as the conclusion.", "requirements": "The provider of the report should make a comment about each image or data included in the report.", "min": 0, "max": "1", "base": { "path": "DiagnosticReport.media.comment", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] }, { "id": "DiagnosticReport.media.link", "path": "DiagnosticReport.media.link", "short": "Reference to the image or data source", "definition": "Reference to the image or data source.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.media.link", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "rim", "map": ".value.reference" } ] }, { "id": "DiagnosticReport.composition", "path": "DiagnosticReport.composition", "short": "Reference to a Composition resource for the DiagnosticReport structure", "definition": "Reference to a Composition resource instance that provides structure for organizing the contents of the DiagnosticReport.", "comment": "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.", "min": 0, "max": "1", "base": { "path": "DiagnosticReport.composition", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Composition" ] } ], "condition": [ "dgr-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "rim", "map": ".value.reference" } ] }, { "id": "DiagnosticReport.conclusion", "path": "DiagnosticReport.conclusion", "short": "Clinical conclusion (interpretation) of test results", "definition": "Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.", "comment": "Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/", "requirements": "Need to be able to provide a conclusion that is not lost among the basic result data.", "alias": [ "Report" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.conclusion", "min": 0, "max": "1" }, "type": [ { "code": "markdown" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)" } ] }, { "id": "DiagnosticReport.conclusionCode", "path": "DiagnosticReport.conclusionCode", "short": "Codes for the clinical conclusion of test results", "definition": "One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.conclusionCode", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/binding-definition", "valueString": "Diagnosis codes provided as adjuncts to the report." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjunctDiagnosis" } ], "strength": "example", "description": "SNOMED CT Clinical Findings", "valueSet": "http://hl7.org/fhir/ValueSet/clinical-findings" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)" } ] }, { "id": "DiagnosticReport.presentedForm", "path": "DiagnosticReport.presentedForm", "short": "Entire report as issued", "definition": "Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.", "comment": "\"application/pdf\" is recommended as the most reliable and interoperable in this context.", "requirements": "Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.presentedForm", "min": 0, "max": "*" }, "type": [ { "code": "Attachment" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "att-1", "severity": "error", "human": "If the Attachment has data, it SHALL have a contentType", "expression": "data.empty() or contentType.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Attachment" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ED/RP" }, { "identity": "rim", "map": "ED" }, { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "text (type=ED)" } ] } ] }, "differential": { "element": [ { "id": "DiagnosticReport.result", "path": "DiagnosticReport.result", "min": 1, "type": [ { "code": "Reference", "profile": [ "https://medavis.com/fhir/StructureDefinition/AIResult" ], "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ] } ] }, { "id": "DiagnosticReport.result.reference", "path": "DiagnosticReport.result.reference", "min": 1 }, { "id": "DiagnosticReport.result.identifier", "path": "DiagnosticReport.result.identifier", "min": 1 }, { "id": "DiagnosticReport.result.identifier.system", "path": "DiagnosticReport.result.identifier.system", "min": 1 }, { "id": "DiagnosticReport.result.identifier.value", "path": "DiagnosticReport.result.identifier.value", "min": 1 }, { "id": "DiagnosticReport.study", "path": "DiagnosticReport.study", "min": 1, "max": "1" }, { "id": "DiagnosticReport.study.identifier", "path": "DiagnosticReport.study.identifier", "min": 1 }, { "id": "DiagnosticReport.study.identifier.system", "path": "DiagnosticReport.study.identifier.system", "min": 1, "fixedUri": "urn:dicom:uid" }, { "id": "DiagnosticReport.study.identifier.value", "path": "DiagnosticReport.study.identifier.value", "short": "The study instance UID", "definition": "The study instance UID with urn:oid: prefix, for example: urn:oid:1.2.276.0.37.1.337.201501.1.123", "min": 1 } ] } }