<status value="draft" /> <publisher value="MedMij" /> <contact> <name value="MedMij" /> <telecom> <system value="email" /> <value value="info@medmij.nl" /> <use value="work" /> </telecom> </contact> <description value="Pathology report which contains the findings and interpretation of a pathology study." /> <purpose value="This DiagnosticReport resource represents the Report building block for patient use cases in the context of the information standard Pathology (Pathologie)." /> <copyright value="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 value="4.0.1" /> <mapping> <identity value="mercurius-core-dataset-2-0" /> <name value="Mercurius Core Dataset 2.0" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="DiagnosticReport" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" /> <derivation value="constraint" /> <differential> <element id="DiagnosticReport"> <path value="DiagnosticReport" /> <short value="Report" /> <definition value="Pathology report which contains the findings and interpretation of a pathology study." /> <alias value="Verslag" /> <alias value="Test" /> <alias value="Result" /> <alias value="Results" /> <alias value="Labs" /> <alias value="Laboratory" /> <constraint> <key value="path-Report-1" /> <severity value="error" /> <human value="The identifier system of a report is of the form 'urn:oid:2.16.840.1.113883.2.4.3.23.3.N.1' where N is the lab number." /> <expression value="identifier.system.startsWith('urn:oid:2.16.840.1.113883.2.4.3.23.3.').endsWith('.1')" /> <source value="http://medmij.nl/fhir/StructureDefinition/path-Report" /> </constraint> <constraint> <key value="path-Report-2" /> <severity value="error" /> <human value="Either a code for cytology or histology is present." /> <expression value="code.coding.where(system = 'http://snomed.info/sct' and code = '1348332002').exists() xor code.coding.where(system = 'http://snomed.info/sct' and code = '252416005').exists()" /> <source value="http://medmij.nl/fhir/StructureDefinition/path-Report" /> </constraint> </element> <element id="DiagnosticReport.identifier"> <path value="DiagnosticReport.identifier" /> <slicing> <discriminator> <type value="value" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="DiagnosticReport.identifier:reportIdentifier"> <path value="DiagnosticReport.identifier" /> <sliceName value="reportIdentifier" /> <short value="ReportIdentifier" /> <definition value="Identifier of the pathology report assigned by the laboratory doing the analysis." /> <comment value="This identifier attains a `.value` of the form _[TCSB]YY-nnnnn_ or _[TCSB]YY-nnnnnn_ (based on the laboratory the report originates from), e.g. T26-012345. The `.system` SHALL be of the form _urn:oid:2.16.840.1.113883.2.4.3.23.3.N.1_ where _N_ is the lab number (i.e. _labid_)." /> <alias value="VerslagIdentificatienummer" /> <alias value="Filler ID" /> <alias value="Placer ID" /> <min value="1" /> <max value="1" /> <condition value="path-Report-1" /> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-3" /> <comment value="rapnaam" /> </mapping> </element> <element id="DiagnosticReport.identifier:reportIdentifier.system"> <path value="DiagnosticReport.identifier.system" /> <min value="1" /> <condition value="path-Report-1" /> </element> <element id="DiagnosticReport.identifier:reportIdentifier.value"> <path value="DiagnosticReport.identifier.value" /> <min value="1" /> </element> <element id="DiagnosticReport.basedOn"> <path value="DiagnosticReport.basedOn" /> <min value="1" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ServiceRequest" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Request" /> </type> </element> <element id="DiagnosticReport.status"> <path value="DiagnosticReport.status" /> <patternCode value="final" /> </element> <element id="DiagnosticReport.category"> <path value="DiagnosticReport.category" /> <slicing> <discriminator> <type value="value" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="DiagnosticReport.category:pathology"> <path value="DiagnosticReport.category" /> <sliceName value="pathology" /> <min value="1" /> <max value="1" /> <patternCodeableConcept> <coding> <system value="http://snomed.info/sct" /> <code value="108257001" /> </coding> </patternCodeableConcept> </element> <element id="DiagnosticReport.code"> <path value="DiagnosticReport.code" /> <comment value="If the pathology study is of type cytology (which means that the ReportIdentifier (i.e. _rapnaam_, mercurius-core-rubriek-3) starts with either _B_ or _C_, corresponding to cervical cytology and other cytology, respectively), SNOMED code _1348332002_ SHALL be used as `.code`. Likewise, if the study is of type histology (in which case the ReportIdentifier starts with _T_), SNOMED code _252416005_ SHALL be used instead. Studies for which the ReportIdentifier starts with _S_ (i.e. autopsies) are out of scope." /> </element> <element id="DiagnosticReport.code.coding"> <path value="DiagnosticReport.code.coding" /> <slicing> <discriminator> <type value="value" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="DiagnosticReport.code.coding:cytology"> <path value="DiagnosticReport.code.coding" /> <sliceName value="cytology" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://snomed.info/sct" /> <code value="1348332002" /> </patternCoding> <condition value="path-Report-2" /> </element> <element id="DiagnosticReport.code.coding:histology"> <path value="DiagnosticReport.code.coding" /> <sliceName value="histology" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://snomed.info/sct" /> <code value="252416005" /> </patternCoding> <condition value="path-Report-2" /> </element> <element id="DiagnosticReport.subject"> <path value="DiagnosticReport.subject" /> <short value="Patient" /> <alias value="Patiënt" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Patient" /> </type> </element> <element id="DiagnosticReport.effective[x]"> <path value="DiagnosticReport.effective[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="DiagnosticReport.effective[x]:effectivePeriod"> <path value="DiagnosticReport.effective[x]" /> <sliceName value="effectivePeriod" /> <min value="1" /> <max value="1" /> <type> <code value="Period" /> </type> </element> <element id="DiagnosticReport.effective[x]:effectivePeriod.start"> <path value="DiagnosticReport.effective[x].start" /> <short value="ReceivedDate" /> <definition value="Date when specimen is received at the laboratory." /> <alias value="DatumOntvangst" /> <min value="1" /> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-80" /> <comment value="datumontvangst" /> </mapping> </element> <element id="DiagnosticReport.effective[x]:effectivePeriod.end"> <path value="DiagnosticReport.effective[x].end" /> <short value="AuthorizationDate" /> <definition value="Date of authorization." /> <alias value="DatumAutorisatie" /> <min value="1" /> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-44" /> <comment value="datumautorisatie" /> </mapping> </element> <element id="DiagnosticReport.resultsInterpreter"> <path value="DiagnosticReport.resultsInterpreter" /> <short value="Authorizer" /> <definition value="Name of the pathologist who has authorized the report." /> <comment value="The actual mapping of the Authorizer concept is on `Practitioner.name[nameInformation].text`." /> <alias value="Autorisator" /> <alias value="Reported by" /> <min value="1" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Practitioner" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/PractitionerRole" /> <targetProfile value="http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-Practitioner" /> <targetProfile value="http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole" /> </type> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-41" /> <comment value="autorisator (implicit, actual mapping is on Practitioner.name[nameInformation].text)" /> </mapping> </element> <element id="DiagnosticReport.specimen"> <path value="DiagnosticReport.specimen" /> <short value="Specimen" /> <definition value="Specimen that will be examined by a laboratory." /> <comment value="Both the primary specimen as well as the individual samples taken from that specimen are referenced here. If only a single sample is taken (i.e. the NumberOfSamples concept is equal to _1_), precisely one Specimen is referenced here, as the primary specimen and sample coincide in that case. If multiple samples have been taken from the primary specimen, the `.specimen` element contains _NumberOfSamples + 1_ references, one for the primary specimen and one for each sample." /> <alias value="Monster" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Specimen" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Request.Specimen" /> </type> </element> <element id="DiagnosticReport.result"> <path value="DiagnosticReport.result" /> <slicing> <discriminator> <type value="profile" /> <path value="resolve()" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="DiagnosticReport.result:clinicalInformation"> <path value="DiagnosticReport.result" /> <sliceName value="clinicalInformation" /> <min value="0" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Report.ClinicalInformation" /> </type> </element> <element id="DiagnosticReport.result:macroscopy"> <path value="DiagnosticReport.result" /> <sliceName value="macroscopy" /> <min value="0" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Report.Macroscopy" /> </type> </element> <element id="DiagnosticReport.result:microscopy"> <path value="DiagnosticReport.result" /> <sliceName value="microscopy" /> <min value="1" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Report.Microscopy" /> </type> </element> <element id="DiagnosticReport.result:protocolData"> <path value="DiagnosticReport.result" /> <sliceName value="protocolData" /> <short value="ProtocolData" /> <definition value="Data from National Palga Protocols, created in the Palga Protocol Module." /> <alias value="Protocoldata" /> <alias value="Atomic Value" /> <alias value="Result" /> <alias value="Atomic result" /> <alias value="Data" /> <alias value="Test" /> <alias value="Analyte" /> <alias value="Battery" /> <alias value="Organizer" /> <min value="0" /> <max value="*" /> <type> <code value="Reference" /> <targetProfile value="http://medmij.nl/fhir/StructureDefinition/path-Report.ProtocolDataItem" /> </type> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-308" /> <comment value="protocoldata" /> </mapping> </element> <element id="DiagnosticReport.conclusion"> <path value="DiagnosticReport.conclusion" /> <short value="Conclusion" /> <definition value="Conclusion of the report." /> <alias value="Conclusie" /> <min value="1" /> <mapping> <identity value="mercurius-core-dataset-2-0" /> <map value="mercurius-core-rubriek-224" /> <comment value="conclusie" /> </mapping> </element> </differential> </StructureDefinition>

No narrative is provided for definitional resources. A human-readable rendering can be found in the implementation guide(s) where this resource is used.