{ "resourceType": "StructureDefinition", "id": "HdBe-TextResult", "language": "en-US", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/resource-effectivePeriod", "valuePeriod": { "start": "2020-08-31T22:00:00+00:00" } } ], "url": "https://fhir.healthdata.be/StructureDefinition/LogicalModel/HdBe-TextResult", "name": "HdBeTextResult", "_name": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "HdBeTekstUitslag" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "title": "HdBe TextResult", "status": "draft", "date": "2022-07-07T15:04:03.2592055+00:00", "publisher": "Healthdata.be (Sciensano)", "contact": [ { "name": "Service portal – healthdata.be", "telecom": [ { "system": "url", "value": "https://sciensano.service-now.com/sp", "use": "work" } ] } ], "description": "Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.\r\n#### Purpose\r\nRecording the results of diagnostic procedures for the purpose of communicating these with the person requesting the procedure and documenting the findings resulting from therapeutic procedures.\r\n#### Evidence Base\r\nMost results of procedures and some laboratory test results are descriptive by nature. This includes reports from radiology, pathology, scopies, ultrasounds, etc. and laboratory tests such as cultures, in which results, interpretation and advice form integral parts of the result. This information model can be used for these (mainly unstructured) results.\r\n\r\nFor laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the LaboratoryTestResult information model. \r\nIn general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) can best be transferred using the LaboratoryTestResult, whereas this information model is better suited for textual results containing more than just a few words. \r\nBoth types of tests occur in almost all laboratories. \r\nApplicability is not determined by the kind of lab but by the kind of result.", "_description": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Een tekstuitslag beschrijft de bevindingen en interpretatie van diagnostische of therapeutische verrichtingen, uitgevoerd op patiënten of monsters afkomstig van de patiënt. \r\n#### Purpose\r\nHet vastleggen van de resultaten van diagnostische verrichtingen ten behoeve van communicatie hiervan met de aanvrager van de verrichting en het documenteren van de bevindingen naar aanleiding van therapeutische verrichtingen.\r\n#### Evidence Base\r\nDe meeste uitslagen van verrichtingen en sommige uitslagen van laboratorium onderzoeken zijn verhalend van aard. Het gaat hierbij om o.a. verslagen van radiologie, pathologie, scopieën, echografie, etc en laboratoriumonderzoeken als banale kweken, waar uitslag, interpretatie en advies integraal onderdeel uitmaken van de uitslag. Deze bouwsteen kan gebruikt worden voor deze niet verder gestructureerde uitslagen.\r\n\r\nBij uitslagen van laboratoriumbepalingen is het moeilijk eenduidig aan te geven wanneer deze bouwsteen gebruikt moet worden en wanneer de bouwsteen LaboratoriumUitslag gebruikt moet worden. \r\nIn het algemeen worden laboratoriumtesten die resulteren in een waarde (7,1 mmol/L), rangtelwoord (++ uit reeks tot ++++) of een kwantitatieve uitslag (Weinig) het beste overgedragen met LaboratoriumUitslag en is deze bouwsteen meer geschikt voor tekstuele uitslagen die langer dan een paar woorden zijn.\r\nIn vrijwel alle laboratoria komen beide soorten testen voor. \r\nDe toepasbaarheid wordt niet door het soort lab maar door het soort uitslag bepaald." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "copyright": "Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.", "fhirVersion": "4.0.1", "kind": "logical", "abstract": true, "type": "https://fhir.healthdata.be/StructureDefinition/LogicalModel/TextResult", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Element", "derivation": "specialization", "snapshot": { "element": [ { "id": "TextResult", "path": "TextResult", "short": "TextResult", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslag" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Rootconcept van de bouwsteen TekstUitslag. Dit rootconcept bevat alle gegevenselementen van de bouwsteen TekstUitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "*", "base": { "path": "TextResult", "min": 0, "max": "*" }, "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "TextResult.id", "path": "TextResult.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "TextResult.extension", "path": "TextResult.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. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "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" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "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()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "TextResult.TextResultDateTime", "path": "TextResult.TextResultDateTime", "short": "TextResultDateTime", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagDatumTijd" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Date and if possible time of the result report.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Datum en eventueel tijdstip van de uitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "1", "base": { "path": "TextResult.TextResultDateTime", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "TextResult.Procedure", "path": "TextResult.Procedure", "short": "Procedure", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Verrichting" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Reference to the Procedure information model including the date of the procedure, requesting and executive specialty.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Verwijzing naar de bouwsteen Verrichting en daarin ook de verrichtingsdatum, aanvragend en uitvoerend specialisme." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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": 0, "max": "1", "base": { "path": "TextResult.Procedure", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.healthdata.be/StructureDefinition/LogicalModel/HdBe-Procedure" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "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.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "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": "TextResult.TextResultStatus", "path": "TextResult.TextResultStatus", "short": "TextResultStatus", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagStatus" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The status of the result.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "De status van de uitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "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": "TextResult.TextResultStatus", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "strength": "extensible", "description": "TextResultStatus codes", "valueSet": "https://fhir.healthdata.be/ValueSet/TekstStatus" }, "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": "TextResult.TextResultReport", "path": "TextResult.TextResultReport", "short": "TextResultReport", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstResultaat" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The text report detailing the actual results of the test or procedure.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Het tekstverslag waarin het feitelijke resultaat van de test of de verrichting staat." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 1, "max": "1", "base": { "path": "TextResult.TextResultReport", "min": 1, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "TextResult.VisualResult", "path": "TextResult.VisualResult", "short": "VisualResult", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "VisueelResultaat" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Visuele onderzoeksresultaten die uitgangspunt van en aanleiding voor het tekstuele verslag zijn. Deze resultaten omvatten zowel beeldmateriaal - bijvoorbeeld radiologische beelden, scopie beelden, medische foto's en video's - als grafische registraties - bijvoorbeeld ECG's, EEG's etc." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "comment": "A stream of bytes, base64 encoded", "min": 0, "max": "*", "base": { "path": "TextResult.VisualResult", "min": 0, "max": "*" }, "type": [ { "code": "base64Binary" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "TextResult.TextResultType", "path": "TextResult.TextResultType", "short": "TextResultType", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagType" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The type of result.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Het soort resultaat." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "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": "TextResult.TextResultType", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "strength": "extensible", "description": "TextResultType codes", "valueSet": "https://fhir.healthdata.be/ValueSet/TekstUitslagType" }, "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" } ] } ] }, "differential": { "element": [ { "id": "TextResult", "path": "TextResult", "short": "TextResult", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslag" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Rootconcept van de bouwsteen TekstUitslag. Dit rootconcept bevat alle gegevenselementen van de bouwsteen TekstUitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "*" }, { "id": "TextResult.TextResultDateTime", "path": "TextResult.TextResultDateTime", "short": "TextResultDateTime", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagDatumTijd" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Date and if possible time of the result report.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Datum en eventueel tijdstip van de uitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "1", "type": [ { "code": "dateTime" } ] }, { "id": "TextResult.Procedure", "path": "TextResult.Procedure", "short": "Procedure", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Verrichting" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Reference to the Procedure information model including the date of the procedure, requesting and executive specialty.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Verwijzing naar de bouwsteen Verrichting en daarin ook de verrichtingsdatum, aanvragend en uitvoerend specialisme." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.healthdata.be/StructureDefinition/LogicalModel/HdBe-Procedure" ] } ] }, { "id": "TextResult.TextResultStatus", "path": "TextResult.TextResultStatus", "short": "TextResultStatus", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagStatus" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The status of the result.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "De status van de uitslag." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "extensible", "description": "TextResultStatus codes", "valueSet": "https://fhir.healthdata.be/ValueSet/TekstStatus" } }, { "id": "TextResult.TextResultReport", "path": "TextResult.TextResultReport", "short": "TextResultReport", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstResultaat" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The text report detailing the actual results of the test or procedure.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Het tekstverslag waarin het feitelijke resultaat van de test of de verrichting staat." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 1, "max": "1", "type": [ { "code": "string" } ] }, { "id": "TextResult.VisualResult", "path": "TextResult.VisualResult", "short": "VisualResult", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "VisueelResultaat" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Visuele onderzoeksresultaten die uitgangspunt van en aanleiding voor het tekstuele verslag zijn. Deze resultaten omvatten zowel beeldmateriaal - bijvoorbeeld radiologische beelden, scopie beelden, medische foto's en video's - als grafische registraties - bijvoorbeeld ECG's, EEG's etc." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 0, "max": "*", "type": [ { "code": "base64Binary" } ] }, { "id": "TextResult.TextResultType", "path": "TextResult.TextResultType", "short": "TextResultType", "_short": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "TekstUitslagType" } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "definition": "The type of result.", "_definition": { "extension": [ { "extension": [ { "url": "lang", "valueCode": "nl-NL" }, { "url": "content", "valueMarkdown": "Het soort resultaat." } ], "url": "http://hl7.org/fhir/StructureDefinition/translation" } ] }, "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "extensible", "description": "TextResultType codes", "valueSet": "https://fhir.healthdata.be/ValueSet/TekstUitslagType" } } ] } }