{ "resourceType": "StructureDefinition", "id": "zib-TextResult", "url": "http://nictiz.nl/fhir/StructureDefinition/zib-TextResult", "version": "2.1.4", "name": "Zib TextResult", "title": "HCIM TextResult", "status": "active", "publisher": "Nictiz", "contact": [ { "name": "Nictiz", "telecom": [ { "system": "url", "value": "https://www.nictiz.nl", "use": "work" } ] } ], "description": "A TextResult as defined by the Dutch Health and Care Information models (Dutch: Zorginformatiebouwsteen or ZIB) version 4.1. Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.\r\n\r\nNote that the HCIM TextResult-v4.1 has NL-CM:13.2.5 Procedure as property of the report. FHIR has this relationship reversed, so the procedure points to the report.", "purpose": "Recording 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.", "copyright": "CC0", "fhirVersion": "3.0.2", "mapping": [ { "identity": "hcim-textresult-v4.1-2017EN", "uri": "https://zibs.nl/wiki/TextResult-v4.1(2017EN)", "name": "HCIM TextResult-v4.1(2017EN)" }, { "identity": "hcim-patient-v3.1-2017EN", "uri": "https://zibs.nl/wiki/Patient-v3.1(2017EN)" }, { "identity": "hcim-healthprofessional-v3.2-2017EN", "uri": "https://zibs.nl/wiki/HealthProfessional-v3.2(2017EN)", "name": "HCIM HealthProfessional-v3.2(2017EN)" }, { "identity": "hcim-basicelements-v1.0-2017EN", "uri": "https://zibs.nl/wiki/BasicElements-v1.0(2017EN)", "name": "HCIM BasicElements-v1.0(2017EN)" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "uri": "https://zibs.nl/wiki/TextResultForTransfer-v3.0(2016EN)", "name": "HCIM TextResultForTransfer-v3.0(2016EN)" }, { "identity": "hcim-patient-v3.0-2016EN", "uri": "https://zibs.nl/wiki/Patient-v3.0(2016EN)", "name": "HCIM Patient-v3.0(2016EN)" }, { "identity": "hcim-healthprofessional-v3.0-2016EN", "uri": "https://zibs.nl/wiki/HealthProfessional-v3.0(2016EN)", "name": "HCIM HealthProfessional-v3.0(2016EN)" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "uri": "https://zibs.nl/wiki/TextResultForTransfer-v1.2.2(2015EN)", "name": "HCIM TextResultForTransfer-v1.2.2(2015EN)" }, { "identity": "hcim-patient-v2.0.1-2015EN", "uri": "https://zibs.nl/wiki/Patient-v2.0.1(2015EN)", "name": "HCIM Patient-v2.0.1(2015EN)" }, { "identity": "hcim-healthprofessional-v1.2.1-2015EN", "uri": "https://zibs.nl/wiki/HealthProfessional-v1.2.1(2015EN)", "name": "HCIM HealthProfessional-v1.2.1(2015EN)" } ], "kind": "resource", "abstract": false, "type": "DiagnosticReport", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "derivation": "constraint", "snapshot": { "element": [ { "id": "DiagnosticReport", "path": "DiagnosticReport", "short": "TextResult", "definition": "Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient. Recording 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.", "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", "TekstUitslag" ], "min": 0, "max": "*", "base": { "path": "Resource", "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()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-1", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain any narrative", "expression": "contained.text.empty()", "xpath": "not(parent::f:contained and f:text)", "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()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "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", "expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()", "xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "v2", "map": "ORU -> OBR" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" }, { "identity": "w5", "map": "clinical.diagnostics" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.1", "comment": "TextResult" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.1", "comment": "TextResult" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.1", "comment": "TextResult" } ] }, { "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": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "code": "id" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "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 may 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" } ], "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" } ], "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.", "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "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" } ], "isModifier": true, "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" } ], "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" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueReference": { "reference": "http://hl7.org/fhir/ValueSet/all-languages" } }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "extensible", "description": "A human language.", "valueSetReference": { "reference": "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 may 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 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 in formation is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1", "dom-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" } ], "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, and nor can they have their own independent transaction scope.", "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "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. 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": "DomainResource.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/Extension" }, { "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": "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. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.", "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.modifierExtension", "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/Extension" }, { "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" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.identifier", "path": "DiagnosticReport.identifier", "short": "Identifier", "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", "Identificatie" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "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" } ], "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 - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. 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": "v2", "map": "OBR-51" }, { "identity": "rim", "map": "id" }, { "identity": "w5", "map": "id" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.6", "comment": "IdentificationNumber" } ] }, { "id": "DiagnosticReport.basedOn", "path": "DiagnosticReport.basedOn", "short": "What was requested", "definition": "Details concerning a test or procedure 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" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/NutritionOrder" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ], "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/Reference" }, { "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)" }, { "identity": "workflow", "map": "Event.basedOn" }, { "identity": "v2", "map": "ORC? OBR-2/3?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "DiagnosticReport.status", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "path": "DiagnosticReport.status", "short": "TextResultStatus", "definition": "The status of the diagnostic report as a whole.", "comment": "This is labeled as \"Is Modifier\" because applications need to take appropriate action if a report is withdrawn.", "requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.", "alias": [ "TekstUitslagStatus" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "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" } ], "isModifier": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticReportStatus" } ], "strength": "required", "description": "The status of the diagnostic report as a whole.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-report-status" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.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\"" }, { "identity": "w5", "map": "status" } ] }, { "id": "DiagnosticReport.status.id", "path": "DiagnosticReport.status.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" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.status.extension", "path": "DiagnosticReport.status.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/Extension" }, { "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": "DiagnosticReport.status.extension:TextResultStatus", "path": "DiagnosticReport.status.extension", "sliceName": "TextResultStatus", "short": "Provides the specific HCIM code for TextResultStatus", "definition": "Defines a more specific value to a code. Especially useful for FHIRs required ValueSets.", "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", "Bevat de specifieke code conform de zib, bij een FHIR-element die een verplichte koppeling heeft met een bepaalde FHIR waardelijst of een FHIR element die niet gecodeerd is gedefinieerd, terwijl de zib dit wel doet.", "TekstUitslagStatus" ], "min": 0, "max": "1", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/code-specification" } ], "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/Extension" }, { "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" } ], "binding": { "strength": "extensible", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20171231000000", "display": "ResultaatStatusCodelijst" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" } ] }, { "id": "DiagnosticReport.status.value", "path": "DiagnosticReport.status.value", "representation": [ "xmlAttr" ], "short": "Primitive value for code", "definition": "Primitive value for code", "min": 0, "max": "1", "base": { "path": "string.value", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-regex", "valueString": "[^\\s]+([\\s]?[^\\s]+)*" } ], "_code": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-json-type", "valueString": "string" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-xml-type", "valueString": "xsd:token" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-rdf-type", "valueString": "xsd:token" } ] } } ], "maxLength": 1048576 }, { "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": "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": "1", "base": { "path": "DiagnosticReport.category", "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" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticServiceSection" } ], "strength": "example", "description": "Codes for diagnostic service sections.", "valueSetReference": { "reference": "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": "v2", "map": "OBR-24" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code" }, { "identity": "w5", "map": "class" } ] }, { "id": "DiagnosticReport.code", "path": "DiagnosticReport.code", "short": "Test", "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", "Onderzoek" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.code", "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" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosticReportCodes" } ], "strength": "extensible", "description": "Codes that describe Diagnostic Reports.", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20171231000000", "display": "TekstUitslagTypeCodelijst" } }, "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": "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" }, { "identity": "w5", "map": "what" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" } ] }, { "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 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.", "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://fhir.nl/fhir/StructureDefinition/nl-core-patient" } ], "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/Reference" }, { "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" } ], "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": "v2", "map": "PID-3 (no HL7 v2 mapping for Group or Device)" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "who.focus" }, { "identity": "hcim-patient-v2.0.1-2015EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-patient-v3.0-2016EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-patient-v3.1-2017EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.11", "comment": "Subject" } ] }, { "id": "DiagnosticReport.context", "path": "DiagnosticReport.context", "short": "Health care event when test ordered", "definition": "The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport per 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 or episode but still be tied to the context of the encounter or episode (e.g. pre-admission lab tests).", "requirements": "Links the request to the Encounter context.", "alias": [ "Encounter" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.context", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-episodeofcare" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-Encounter" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/gp-Encounter" } ], "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/Reference" }, { "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" } ], "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.context" }, { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" }, { "identity": "w5", "map": "context" } ] }, { "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" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "v2", "map": "OBR-7" }, { "identity": "rim", "map": "effectiveTime" }, { "identity": "w5", "map": "when.done" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.14", "comment": "DateTime" } ] }, { "id": "DiagnosticReport.issued", "path": "DiagnosticReport.issued", "short": "DateTime this version was released", "definition": "The date and time that this version of the report was released from the source diagnostic service.", "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 Created", "Date published", "Date Issued" ], "min": 0, "max": "1", "base": { "path": "DiagnosticReport.issued", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBR-22" }, { "identity": "rim", "map": "participation[typeCode=VRF or AUT].time" }, { "identity": "w5", "map": "when.recorded" } ] }, { "id": "DiagnosticReport.performer", "path": "DiagnosticReport.performer", "short": "Participants in producing the report", "definition": "Indicates who or what participated in producing the report.", "alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.performer", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.performer" }, { "identity": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": ".participation[typeCode=PRF]" }, { "identity": "w5", "map": "who.witness" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.7", "comment": "Author" } ] }, { "id": "DiagnosticReport.performer.id", "path": "DiagnosticReport.performer.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" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.performer.extension", "path": "DiagnosticReport.performer.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/Extension" }, { "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": "DiagnosticReport.performer.modifierExtension", "path": "DiagnosticReport.performer.modifierExtension", "short": "Extensions that cannot be ignored", "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 that contains it. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.", "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", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "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/Extension" }, { "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" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.performer.role", "path": "DiagnosticReport.performer.role", "short": "Type of performer", "definition": "Describes the type of participation (e.g. a responsible party, author, or verifier).", "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": "DiagnosticReport.performer.role", "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" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Role" } ], "strength": "example", "description": "Indicate a role of diagnostic report performer", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/performer-role" } }, "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.performer.role" }, { "identity": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": ".functionCode" } ] }, { "id": "DiagnosticReport.performer.role.id", "path": "DiagnosticReport.performer.role.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" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.performer.role.extension", "path": "DiagnosticReport.performer.role.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/Extension" }, { "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": "DiagnosticReport.performer.role.coding", "path": "DiagnosticReport.performer.role.coding", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "DiagnosticReport.performer.role.coding:healthProfessionalRole", "path": "DiagnosticReport.performer.role.coding", "sliceName": "healthProfessionalRole", "short": "HealthProfessionalRole", "definition": "The role the healthcare provider fulfils in the healthcare process. For healthcare providers, this could be for example main practitioner, referrer or general practitioner.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "alias": [ "ZorgverlenerRol" ], "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "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" } ], "isSummary": true, "binding": { "strength": "required", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.17.1.5--20171231000000", "display": "ZorgverlenerRolCodelijst" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" }, { "identity": "hcim-healthprofessional-v1.2.1-2015EN", "map": "NL-CM:17.1.5", "comment": "HealthcareProviderRole" }, { "identity": "hcim-healthprofessional-v3.0-2016EN", "map": "NL-CM:17.1.5", "comment": "HealthcareProviderRole" }, { "identity": "hcim-healthprofessional-v3.2-2017EN", "map": "NL-CM:17.1.5", "comment": "HealthProfessionalRole" } ] }, { "id": "DiagnosticReport.performer.role.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DiagnosticReport.performer.role.text", "short": "Plain text representation of the concept", "definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "DiagnosticReport.performer.actor", "path": "DiagnosticReport.performer.actor", "short": "Practitioner or Organization participant", "definition": "The reference to the practitioner or organization involved in producing the report. For example, the diagnostic service that is responsible for issuing the report.", "comment": "This is not necessarily the source of the atomic data items. 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.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.performer.actor", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-organization" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner" } ], "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/Reference" }, { "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" } ], "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": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": ".role" } ] }, { "id": "DiagnosticReport.performer.actor.id", "path": "DiagnosticReport.performer.actor.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" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.performer.actor.extension", "path": "DiagnosticReport.performer.actor.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/Extension" }, { "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": "DiagnosticReport.performer.actor.extension:practitionerRole", "path": "DiagnosticReport.performer.actor.extension", "sliceName": "practitionerRole", "short": "Optional Extensions Element", "definition": "Optional Extension Element - found in all resources.", "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": "1", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference" } ], "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/Extension" }, { "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": "DiagnosticReport.performer.actor.reference", "path": "DiagnosticReport.performer.actor.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": [ "ele-1", "ref-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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.performer.actor.identifier", "path": "DiagnosticReport.performer.actor.identifier", "short": "Logical reference, when literal reference is not known", "definition": "An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.", "min": 0, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "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" } ], "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 - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. 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.performer.actor.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DiagnosticReport.performer.actor.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": [ "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "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" } ], "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/Reference" }, { "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)" }, { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "id": "DiagnosticReport.result", "path": "DiagnosticReport.result", "short": "Observations - simple, or complex nested groups", "definition": "Observations that are part of this diagnostic report. Observations can be simple name/value pairs (e.g. \"atomic\" results), or they can be grouping observations that include references to other members of the group (e.g. \"panels\").", "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.", "requirements": "Need to support individual results, or report groups of results, where the result grouping is arbitrary, but meaningful. This structure is recursive - observations can contain observations.", "alias": [ "Data", "Atomic Value", "Result", "Atomic result", "Data", "Test", "Analyte", "Battery", "Organizer" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.result", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "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/Reference" }, { "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)" }, { "identity": "v2", "map": "OBXs" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "id": "DiagnosticReport.imagingStudy", "path": "DiagnosticReport.imagingStudy", "short": "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.", "comment": "ImagingStudy and ImageManifest 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.", "min": 0, "max": "*", "base": { "path": "DiagnosticReport.imagingStudy", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ImagingManifest" } ], "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/Reference" }, { "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)" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]" } ] }, { "id": "DiagnosticReport.image", "path": "DiagnosticReport.image", "short": "Key images associated with this report", "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.", "alias": [ "DICOM", "Slides", "Scans" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport.image", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "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" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "id": "DiagnosticReport.image.id", "path": "DiagnosticReport.image.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" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DiagnosticReport.image.extension", "path": "DiagnosticReport.image.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/Extension" }, { "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": "DiagnosticReport.image.modifierExtension", "path": "DiagnosticReport.image.modifierExtension", "short": "Extensions that cannot be ignored", "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 that contains it. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.", "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", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "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/Extension" }, { "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" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DiagnosticReport.image.comment", "path": "DiagnosticReport.image.comment", "short": "Comment about the image (e.g. explanation)", "definition": "A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.", "comment": "The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.", "requirements": "The provider of the report should make a comment about each image included in the report.", "min": 0, "max": "1", "base": { "path": "DiagnosticReport.image.comment", "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" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] }, { "id": "DiagnosticReport.image.link", "path": "DiagnosticReport.image.link", "short": "Reference to the image source", "definition": "Reference to the image source.", "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": 1, "max": "1", "base": { "path": "DiagnosticReport.image.link", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Media" } ], "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/Reference" }, { "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" } ], "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.conclusion", "path": "DiagnosticReport.conclusion", "short": "Clinical Interpretation of test results", "definition": "Concise and clinically contextualized impression / summary of the diagnostic report.", "comment": "Note that FHIR strings may not exceed 1MB in size", "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": "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" } ], "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)" }, { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" } ] }, { "id": "DiagnosticReport.codedDiagnosis", "path": "DiagnosticReport.codedDiagnosis", "short": "Codes for the conclusion", "definition": "Codes for the conclusion.", "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.codedDiagnosis", "min": 0, "max": "*" }, "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" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjunctDiagnosis" } ], "strength": "example", "description": "Diagnosis codes provided as adjuncts to the report.", "valueSetReference": { "reference": "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" } ], "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/Attachment" }, { "key": "att-1", "severity": "error", "human": "It the Attachment has data, it SHALL have a contentType", "expression": "data.empty() or contentType.exists()", "xpath": "not(exists(f:data)) or exists(f:contentType)", "source": "http://hl7.org/fhir/StructureDefinition/Attachment" } ], "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", "path": "DiagnosticReport", "short": "TextResult", "definition": "Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient. Recording 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.", "alias": [ "TekstUitslag" ], "mapping": [ { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.1", "comment": "TextResult" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.1", "comment": "TextResult" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.1", "comment": "TextResult" } ] }, { "id": "DiagnosticReport.identifier", "path": "DiagnosticReport.identifier", "short": "Identifier", "alias": [ "Identificatie" ], "mapping": [ { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.6", "comment": "IdentificationNumber" } ] }, { "id": "DiagnosticReport.status", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "path": "DiagnosticReport.status", "short": "TextResultStatus", "alias": [ "TekstUitslagStatus" ] }, { "id": "DiagnosticReport.status.extension", "path": "DiagnosticReport.status.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "rules": "open" } }, { "id": "DiagnosticReport.status.extension:TextResultStatus", "path": "DiagnosticReport.status.extension", "sliceName": "TextResultStatus", "short": "Provides the specific HCIM code for TextResultStatus", "definition": "Defines a more specific value to a code. Especially useful for FHIRs required ValueSets.", "alias": [ "TekstUitslagStatus" ], "max": "1", "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/code-specification" } ], "binding": { "strength": "extensible", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20171231000000", "display": "ResultaatStatusCodelijst" } }, "mapping": [ { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.6", "comment": "TextResultStatus" } ] }, { "id": "DiagnosticReport.code", "path": "DiagnosticReport.code", "short": "Test", "alias": [ "Onderzoek" ], "binding": { "strength": "extensible", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20171231000000", "display": "TekstUitslagTypeCodelijst" } }, "mapping": [ { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.4", "comment": "TextResultType" } ] }, { "id": "DiagnosticReport.subject", "path": "DiagnosticReport.subject", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-patient" } ], "mapping": [ { "identity": "hcim-patient-v2.0.1-2015EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-patient-v3.0-2016EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-patient-v3.1-2017EN", "map": "NL-CM:0.1.1", "comment": "Patient" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.11", "comment": "Subject" } ] }, { "id": "DiagnosticReport.context", "path": "DiagnosticReport.context", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-episodeofcare" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-Encounter" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/gp-Encounter" } ] }, { "id": "DiagnosticReport.effective[x]", "path": "DiagnosticReport.effective[x]", "mapping": [ { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.3", "comment": "TextResultDateTime" }, { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.14", "comment": "DateTime" } ] }, { "id": "DiagnosticReport.performer", "path": "DiagnosticReport.performer", "mapping": [ { "identity": "hcim-basicelements-v1.0-2017EN", "map": "NL-CM:0.0.7", "comment": "Author" } ] }, { "id": "DiagnosticReport.performer.role.coding", "path": "DiagnosticReport.performer.role.coding", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" } }, { "id": "DiagnosticReport.performer.role.coding:healthProfessionalRole", "path": "DiagnosticReport.performer.role.coding", "sliceName": "healthProfessionalRole", "short": "HealthProfessionalRole", "definition": "The role the healthcare provider fulfils in the healthcare process. For healthcare providers, this could be for example main practitioner, referrer or general practitioner.", "alias": [ "ZorgverlenerRol" ], "binding": { "strength": "required", "valueSetReference": { "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.17.1.5--20171231000000", "display": "ZorgverlenerRolCodelijst" } }, "mapping": [ { "identity": "hcim-healthprofessional-v1.2.1-2015EN", "map": "NL-CM:17.1.5", "comment": "HealthcareProviderRole" }, { "identity": "hcim-healthprofessional-v3.0-2016EN", "map": "NL-CM:17.1.5", "comment": "HealthcareProviderRole" }, { "identity": "hcim-healthprofessional-v3.2-2017EN", "map": "NL-CM:17.1.5", "comment": "HealthProfessionalRole" } ] }, { "id": "DiagnosticReport.performer.actor", "path": "DiagnosticReport.performer.actor", "type": [ { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-organization" }, { "code": "Reference", "targetProfile": "http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner" } ] }, { "id": "DiagnosticReport.performer.actor.extension", "path": "DiagnosticReport.performer.actor.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "rules": "open" } }, { "id": "DiagnosticReport.performer.actor.extension:practitionerRole", "path": "DiagnosticReport.performer.actor.extension", "sliceName": "practitionerRole", "max": "1", "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference" } ] }, { "id": "DiagnosticReport.conclusion", "path": "DiagnosticReport.conclusion", "mapping": [ { "identity": "hcim-textresultfortransfer-v1.2-2015EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" }, { "identity": "hcim-textresultfortransfer-v3.0-2016EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" }, { "identity": "hcim-textresult-v4.1-2017EN", "map": "NL-CM:13.2.2", "comment": "TextResultReport" } ] } ] } }