Diagnostic Report

Description

This structure specifies a report and outcomes of the colonoscopy. It refers to individual observations made during the colonscopy, and reports the main and possible secondary diagnoses. The main diagnoses had to be marked with the "IsMainDiagnosis" extension.

Structure

identifierΣ0..*Identifier
basedOnI0..0Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
statusΣ ?!1..1codeBinding
categoryΣ0..0CodeableConcept
SNOMED-CTΣ1..1Coding
textΣ0..1string
subjectS Σ I0..1Reference(Patient | Group | Device | Location)
encounterΣ I0..0Reference(Encounter)
issuedΣ0..0instant
performerΣ I0..0Reference(Practitioner | PractitionerRole | Organization | CareTeam)
resultsInterpreterΣ I0..0Reference(Practitioner | PractitionerRole | Organization | CareTeam)
specimenI0..0Reference(Specimen)
BostonBowelPreparationScaleS I0..1Reference(Gastronet Boston Bowel Preparation Scale)
NumberOfLesionsS I0..1Reference(Gastronet Number Of Lesions)
LumenS I0..*Reference(Gastronet Lumen)
imagingStudyI0..0Reference(ImagingStudy)
conclusion0..0string
IsMainDiagnosisS I0..1Extension(boolean)
ICD-10S Σ1..1Coding
textΣ0..1string
presentedFormI0..0Attachment

Example