Implementation Guide DIFUTURE

TrustcenterDiagnosticReport

The resource TrustcenterDiagnosticReport is a modified resource of the profile DiagnosticReport and is used e.g. to represent results from the laboratory or pathology. It consists of the elements identifier, status and code. If a summary is requested with the command summary=true, all these elements are displayed.

Properties and constraints

There must be at least one (1..*) identifier of the type Identifier. This can and must be specialized in this case by specifying exactly one (1..1) officialIdentifier (fixed values: use = official). However, other identifiers can be defined, e.g. with the use usual, temp, secondary or old. In addition, the officialIdentifier is marked as must support therefore the later implementation should be able to process this meaningfully.

The attributes status or code of type code or CodeableConcept, respectively, are already stipulated by the super resource and must be specified exactly once. The first specifies the status of the results, whereby its values must come from a certain value set (binding-strength = required). Here, they come from the set diagnostic-report-status. For the attribute code, the value set requirement is less strict therefore it is not necessary to select from the set report-codes but it would be recommended (binding-strength = preferred).

TrustcenterDiagnosticReport (DiagnosticReport)	I		DiagnosticReport	There are no (further) constraints on this element Element id DiagnosticReport Short description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate names Report, Test, Result, Results, Labs, Laboratory Definition The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. Comments 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. Data type DiagnosticReport Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` Mappings rim: Entity. Role, or Act workflow: Event v2: ORU -> OBR rim: Observation[classCode=OBS, moodCode=EVN]
id	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.id Short description 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. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id DiagnosticReport.meta Short description 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. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id DiagnosticReport.implicitRules Short description 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. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
language		0..1	codeBinding	There are no (further) constraints on this element Element id DiagnosticReport.language Short description Language of the resource content Definition The base language in which the resource is written. Comments 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). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
text		0..1	Narrative	There are no (further) constraints on this element Element id DiagnosticReport.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display 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. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id DiagnosticReport.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments 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. Data type Resource Mappings rim: Entity. Role, or Act rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.extension Short description Additional content defined by implementations Alternate names extensions, user content 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
identifier	Σ	1..*	Identifier	Element id DiagnosticReport.identifier Short description Business identifier for report Alternate names ReportID, Filler ID, Placer ID Definition Identifiers assigned to this report by the performer or other systems. 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. Comments Usually assigned by the Information System of the diagnostic service provider (filler id). Data type Identifier Sliced: Unordered, Open, by use(Value) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: 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] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier v2: 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 rim: id
officialIdentifier	S Σ	1..1	Identifier	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier Short description Business identifier for report Alternate names ReportID, Filler ID, Placer ID Definition Identifiers assigned to this report by the performer or other systems. 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. Comments Usually assigned by the Information System of the diagnostic service provider (filler id). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: 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] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier v2: 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 rim: id
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.id Short description 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. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.extension Short description Additional content defined by implementations Alternate names extensions, user content 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
use	Σ ?!	1..1	codeBindingFixed Value	Element id DiagnosticReport.identifier:officialIdentifier.use Short description usual \| official \| temp \| secondary \| old (If known) Definition The purpose of this identifier. Requirements Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Comments Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Data type code Binding Identifies the purpose for this identifier, if known . IdentifierUse (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed value official Mappings rim: n/a v2: N/A rim: Role.code or implied by context
type	Σ	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.type Short description Description of identifier Definition A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Requirements Allows users to make use of identifiers when the identifier system is not known. Comments 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. Data type CodeableConcept Binding A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: CX.5 rim: Role.code or implied by context
system	Σ	0..1	uri	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.system Short description The namespace for the identifier value Definition Establishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Comments Identifier.system is always case sensitive. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples General http://www.acme.com/identifiers/patient Mappings rim: n/a v2: CX.4 / EI-2-4 rim: II.root or Role.id.root servd: ./IdentifierType
value	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.value Short description 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. Comments 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 Rendered Value extension. 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples General 123456 Mappings rim: n/a v2: CX.1 / EI.1 rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root) servd: ./Value
period	Σ I	0..1	Period	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.period Short description Time period when id is/was valid for use Definition Time period during which identifier is/was valid for use. Comments 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"). Period is not used for a duration (a measure of elapsed time). See Duration. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` per-1: If present, start SHALL have a lower value than end `start.hasValue().not() or end.hasValue().not() or (start <= end)` Mappings rim: n/a v2: DR rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] v2: CX.7 + CX.8 rim: Role.effectiveTime or implied by context servd: ./StartDate and ./EndDate
assigner	Σ I	0..1	Reference(Organization)	There are no (further) constraints on this element Element id DiagnosticReport.identifier:officialIdentifier.assigner Short description Organization that issued id (may be just text) Definition Organization that issued/manages the identifier. Comments 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. Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2: CX.4 / (CX.4,CX.9,CX.10) rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper servd: ./IdentifierIssuingAuthority
basedOn	I	0..0	Reference(CarePlan \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	There are no (further) constraints on this element Element id DiagnosticReport.basedOn Short description What was requested Alternate names Request Definition Details concerning a service requested. Requirements This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Comments 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. Data type Reference(CarePlan \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.basedOn v2: ORC? OBR-2/3? rim: outboundRelationship[typeCode=FLFS].target
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id DiagnosticReport.status Short description registered \| partial \| preliminary \| final + Definition The status of the diagnostic report. Requirements Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Binding The status of the diagnostic report. DiagnosticReportStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.status w5: FiveWs.status v2: OBR-25 (not 1:1 mapping) rim: statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
category	Σ	0..0	CodeableConcept	There are no (further) constraints on this element Element id DiagnosticReport.category Short description Service category Alternate names Department, Sub-department, Service, Discipline 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. Comments 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. Data type CodeableConcept Binding Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD w5: FiveWs.class v2: OBR-24 rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
code	Σ	1..1	CodeableConceptBinding	There are no (further) constraints on this element Element id DiagnosticReport.code Short description Name/Code for this diagnostic report Alternate names Type Definition A code or name that describes this diagnostic report. Comments 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. Data type CodeableConcept Binding Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel) rim: code
subject	Σ I	0..0	Reference(Patient \| Group \| Device \| Location)	There are no (further) constraints on this element Element id DiagnosticReport.subject Short description The subject of the report - usually, but not always, the patient Alternate names 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. Requirements SHALL know the subject context. Comments 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. Data type Reference(Patient \| Group \| Device \| Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 (no HL7 v2 mapping for Group or Device) rim: participation[typeCode=SBJ] w5: FiveWs.subject
encounter	Σ I	0..0	Reference(Encounter)	There are no (further) constraints on this element Element id DiagnosticReport.encounter Short description Health care event when test ordered Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Requirements Links the request to the Encounter context. Comments 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). Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.encounter w5: FiveWs.context v2: PV1-19 rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
effective[x]	Σ	0..0		There are no (further) constraints on this element Element id DiagnosticReport.effective[x] Short description Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence 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. Requirements Need to know where in the patient history to file/present this report. Comments 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. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: effectiveTime
issued	Σ	0..0	instant	There are no (further) constraints on this element Element id DiagnosticReport.issued Short description DateTime this version was made Alternate names Date published, Date Issued, Date Verified Definition The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Requirements Clinicians need to be able to check the date that the report was released. Comments 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. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a w5: FiveWs.recorded v2: OBR-22 rim: participation[typeCode=VRF or AUT].time
performer	Σ I	0..0	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	There are no (further) constraints on this element Element id DiagnosticReport.performer Short description Responsible Diagnostic Service Alternate names Laboratory, Service, Practitioner, Department, Company, Authorized by, Director Definition The diagnostic service that is responsible for issuing the 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. Comments 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. Data type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer.actor w5: FiveWs.actor v2: PRT-8 (where this PRT-4-Participation = "PO") rim: .participation[typeCode=PRF]
resultsInterpreter	Σ I	0..0	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	There are no (further) constraints on this element Element id DiagnosticReport.resultsInterpreter Short description Primary result interpreter Alternate names Analyzed by, Reported by Definition The practitioner or organization that is responsible for the report's conclusions and interpretations. 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. Comments Might not be the same entity that takes responsibility for the clinical report. Data type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer.actor w5: FiveWs.actor v2: OBR-32, PRT-8 (where this PRT-4-Participation = "PI") rim: .participation[typeCode=PRF]
specimen	I	0..0	Reference(Specimen)	There are no (further) constraints on this element Element id DiagnosticReport.specimen Short description Specimens this report is based on Definition Details about the specimens on which this diagnostic report is based. Requirements Need to be able to report information about the collected specimens on which the report is based. Comments 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. Data type Reference(Specimen) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2: SPM rim: participation[typeCode=SBJ]
result	I	0..0	Reference(Observation)	There are no (further) constraints on this element Element id DiagnosticReport.result Short description Observations Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Observations that are part of this diagnostic report. Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Comments Observations can contain observations. Data type Reference(Observation) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2: OBXs rim: outboundRelationship[typeCode=COMP].target
imagingStudy	I	0..0	Reference(ImagingStudy)	There are no (further) constraints on this element Element id DiagnosticReport.imagingStudy Short description Reference to full details of imaging associated with the diagnostic report Definition One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. Comments ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. Data type Reference(ImagingStudy) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
media	Σ	0..0	BackboneElement	There are no (further) constraints on this element Element id DiagnosticReport.media Short description Key images associated with this report Alternate names DICOM, Slides, Scans Definition A list of key images associated with this report. The images 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 in the report as part of their service. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: OBX? rim: outboundRelationship[typeCode=COMP].target
conclusion		0..0	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusion Short description Clinical conclusion (interpretation) of test results Alternate names Report Definition Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Requirements Need to be able to provide a conclusion that is not lost among the basic result data. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: OBX rim: inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
conclusionCode		0..0	CodeableConcept	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode Short description Codes for the clinical conclusion of test results Definition One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Comments 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. Data type CodeableConcept Binding Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: OBX rim: inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
presentedForm	I	0..0	Attachment	There are no (further) constraints on this element Element id DiagnosticReport.presentedForm Short description 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. Requirements Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. Comments "application/pdf" is recommended as the most reliable and interoperable in this context. Data type Attachment Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` att-1: If the Attachment has data, it SHALL have a contentType `data.empty() or contentType.exists()` Mappings rim: n/a v2: ED/RP rim: ED v2: OBX rim: text (type=ED)