<status value="draft" /> <date value="2021-10-26T16:11:23.170438+00:00" /> <publisher value="OMD" /> <description value="Proposed constraints on the DiagnosticReport resource for the minimal set of data to query and retrieve diagnostic reports associated with laboratory and other results" /> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166" /> <code value="CA" /> <display value="Canada" /> </coding> </jurisdiction> <fhirVersion value="4.0.1" /> <mapping> <identity value="CDSS5.1" /> <uri value="www.ontariomd.com" /> <name value="CDS-S 5.1" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="DiagnosticReport" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" /> <derivation value="constraint" /> <differential> <element id="DiagnosticReport"> <path value="DiagnosticReport" /> <short value="DiagnosticReport Profile" /> <definition value="Diagnostic Report Profile is based upon the core FHIR DiagnosticReport resource and created to meet the Laboratory test(s) and Laboratory value(s)/result(s) requirements." /> </element> <element id="DiagnosticReport.identifier.value"> <path value="DiagnosticReport.identifier.value" /> <definition value="BASE RESOURCE DEFINITION: The portion of the identifier typically relevant to the user and which is unique within the context of the system. CDS-S PROFILE DEFINITION (Laboratory Test Results - Accession Number): The unique number assigned by the source to one test or a group of tests to be performed. CDS-S PROFILE DEFINITION (Reports Received - Source Facility Report Number): Unique ID for a report as provided by the sending facility. This discrete data element is specific to reports downloaded from "HRM system"." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.007" /> <comment value="Source Facility Report Number" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE10.005" /> <comment value="Accession Number" /> </mapping> </element> <element id="DiagnosticReport.basedOn"> <path value="DiagnosticReport.basedOn" /> <definition value="BASE RESOURCE DEFINITION: Details concerning a service requested. CDS-S PROFILE DEFINITION: The date & time that the lab test was ordered within the EMR." /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.018" /> <comment value="Lab Requisition Date/Time" /> </mapping> </element> <element id="DiagnosticReport.status"> <path value="DiagnosticReport.status" /> <definition value="BASE RESOURCE DEFINITION: The status of the diagnostic report. CDS-S PROFILE DEFINITION: The status of the report as received from the source. This discrete data element is specific to the reports downloaded from "HRM system"." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.015" /> <comment value="Report Status" /> </mapping> </element> <element id="DiagnosticReport.category"> <path value="DiagnosticReport.category" /> <slicing> <discriminator> <type value="pattern" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <definition value="BASE RESOURCE 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. CDS-S PROFILE DEFINITION: Classification of the external reports received by the practice." /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.009" /> <comment value="Report Class" /> </mapping> </element> <element id="DiagnosticReport.category:LabResult"> <path value="DiagnosticReport.category" /> <sliceName value="LabResult" /> <definition value="A code that classifies the Laboratory test(s) and Laboratory result(s). This is used for searching, sorting and display purposes." /> <comment value="Multiple categories are allowed using various categorization schemes but at least one SHALL come from the FHIR defined value set that includes codes from HL7v2 Table 0074" /> <min value="1" /> <max value="1" /> </element> <element id="DiagnosticReport.category:LabResult.coding.system"> <path value="DiagnosticReport.category.coding.system" /> <min value="1" /> <fixedUri value="http://terminology.hl7.org/CodeSystem/v2-0074" /> </element> <element id="DiagnosticReport.code"> <path value="DiagnosticReport.code" /> <definition value="BASE RESOURCE DEFINITION: A code or name that describes this diagnostic report. CDS-S PROFILE DEFINITION (Reports Received - Report Sub-Class): Sub-classification of the external reports. CDS-S PROFILE DEFINITION (Reports Received - Accompanying Sub-Class): The sub-classification of the Diagnostic Imaging (DI) and Cardio Respiratory Therapy (CRT) reports as provided by the sending facility (source facility). This discrete data element is specific to DI and CRT reports downloaded from "HRM system". CDS-S PROFILE DEFINITION (Reports Received - Accompanying Mnemonic): The abbreviated term used by the sending facility to describe procedures/studies as provided by the sending facility. This discrete data element is specific to DI and CRT reports downloaded from "HRM system". CDS-S PROFILE DEFINITION (Reports Received - Accompanying Description): The description of a procedure/study corresponding to the Accompanying Mnemonic data element as provided by the sending facility. This Discrete data element is specific to DI and CRT reports downloaded from "HRM system"." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.010" /> <comment value="Report Sub-Class" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.011" /> <comment value="Accompanying Sub-Class" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.012" /> <comment value="Accompanying Mnemonic" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.013" /> <comment value="Accompanying Description" /> </mapping> </element> <element id="DiagnosticReport.code.coding.code"> <path value="DiagnosticReport.code.coding.code" /> <definition value="BASE RESOURCE DEFINITION: A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). CDS-S PROFILE DEFINITION (Laboratory Test Results - Laboratory Test Code): (DiagnosticReport.code.coding.code[0]) The proprietaty code that uniquely identifies a test within a laboratory as provided by the source. CDS-S PROFILE DEFINITION (Laboratory Test Results - EMR Test Name): (DiagnosticReport.code.coding.code[1]) The EMR's proprietary name of a laboratory test for the purpose of uniquely representing and cross-referencing the same text received from different laboratory sources." /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.002" /> <comment value="Laboratory Test Code" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE10.004" /> <comment value="EMR Test Name" /> </mapping> </element> <element id="DiagnosticReport.code.coding.display"> <path value="DiagnosticReport.code.coding.display" /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.003" /> <comment value="Laboratory Test Name" /> </mapping> </element> <element id="DiagnosticReport.subject"> <path value="DiagnosticReport.subject" /> <type> <code value="Reference" /> <targetProfile value="https://simplifier.net/omd-cdss/patientprofile" /> <targetProfile value="https://simplifier.net/omd-cdss/locationprofile" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.encounter"> <path value="DiagnosticReport.encounter" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-encounter" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.effective[x]"> <path value="DiagnosticReport.effective[x]" /> <short value="Time of the report or note" /> <definition value="This is the Datetime or Period when the report or note was written." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.issued"> <path value="DiagnosticReport.issued" /> <definition value="BASE RESOURCE DEFINITION: The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. CDS-S PROFILE DEFINITION: The date and time that the medical and non medical report was created by the source provider (author) or souce facility." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.004" /> <comment value="Creation Date" /> </mapping> </element> <element id="DiagnosticReport.performer"> <path value="DiagnosticReport.performer" /> <definition value="BASE RESOURCE DEFINITION: The diagnostic service that is responsible for issuing the report. CDS-S PROFILE DEFINITION (Laboratory Test Results): The name of the laboratory (source) responsible for sending the test results to the EMR. CDS-S PROFILE DEFINITION (Reports Received - Source Facility): The name of the facility (clinic, hospital) where the report originated (e.g., Trillium Hospital, Sick Kids Hospital). CDS-S PROFILE DEFINITION (Reports Received - Source Facility ID): Unique ID of the facility that sends HRM reports. This discrete data element is specific to reports downloaded from "HRM system"." /> <type> <code value="Reference" /> <targetProfile value="https://simplifier.net/omd-cdss/practitionerprofile" /> <targetProfile value="https://simplifier.net/omd-cdss/organizationprofile" /> </type> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.001" /> <comment value="Laboratory Name" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.001" /> <comment value="Source Facility" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.002" /> <comment value="Source Facility ID" /> </mapping> </element> <element id="DiagnosticReport.resultsInterpreter"> <path value="DiagnosticReport.resultsInterpreter" /> <definition value="BASE RESOURCE DEFINITION: The practitioner or organization that is responsible for the report's conclusions and interpretations. CDS-S PROFILE DEFINITION (Laboratory Test Results - Reviewer Identity): The identity of the authorized provider who signed-off (reviewed) the lab result(s). CDS-S PROFILE DEFINITION (Reports Received - Responsible Provider): The EMR user that is responsible for reviewing the report. CDS-S PROFILE DEFINITION (Reports Received - Reviewer Identity): The authorized provider who signed off (reviewed) the report." /> <type> <code value="Reference" /> <targetProfile value="https://simplifier.net/omd-cdss/practitionerprofile" /> <targetProfile value="https://simplifier.net/omd-cdss/organizationprofile" /> </type> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.020" /> <comment value="Reviewer Identity" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.016" /> <comment value="Responsible Provider" /> </mapping> <mapping> <identity value="CDSS5.1" /> <map value="DE14.017" /> <comment value="Reviewer Identity" /> </mapping> </element> <element id="DiagnosticReport.specimen"> <path value="DiagnosticReport.specimen" /> <slicing> <discriminator> <type value="pattern" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <definition value="BASE RESOURCE DEFINITION: Details about the specimens on which this diagnostic report is based. CDS-S PROFILE DEFINITION: Date time the specimen was collected" /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE10.006" /> <comment value="Collection Date/Time" /> </mapping> </element> <element id="DiagnosticReport.specimen:LabResult"> <path value="DiagnosticReport.specimen" /> <sliceName value="LabResult" /> <comment value="Details about the specimen(s) on which this laboratory report is based on." /> <min value="1" /> </element> <element id="DiagnosticReport.specimen:@default"> <path value="DiagnosticReport.specimen" /> <sliceName value="@default" /> <comment value="Details about specimen(s) on which this report is based on." /> </element> <element id="DiagnosticReport.result"> <path value="DiagnosticReport.result" /> <slicing> <discriminator> <type value="profile" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <definition value="BASE RESOURCE DEFINITION: [Observations](observation.html) that are part of this diagnostic report. CDS-S PROFILE DEFINITION: The date and time that the observation/service was performed for each Diagnostic Imaging (DI) and Cardio Respiratory Therapy (CRT) report as provided by the sending facility (source facility). This discrete data element is specific to DI and CRT reports downloaded from "HRM system"." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.014" /> <comment value="Observation Date/Time" /> </mapping> </element> <element id="DiagnosticReport.result:LabResult"> <path value="DiagnosticReport.result" /> <sliceName value="LabResult" /> <comment value="Observations that represent results produced by laboratory tests or panels/studies" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-observation-results" /> </type> </element> <element id="DiagnosticReport.result:@default"> <path value="DiagnosticReport.result" /> <sliceName value="@default" /> <comment value="Observations that represent results produced for report" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-observation" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.conclusion"> <path value="DiagnosticReport.conclusion" /> <definition value="BASE RESOURCE DEFINITION: Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. CDS-S PROFILE DEFINITION: Additional notes/annotations about the report (attached file) as typed in by the provider." /> <mustSupport value="true" /> <mapping> <identity value="CDSS5.1" /> <map value="DE14.008" /> <comment value="Notes" /> </mapping> </element> <element id="DiagnosticReport.conclusionCode"> <path value="DiagnosticReport.conclusionCode" /> <short value="CHI identification of the condition, problem or diagnosis" /> <definition value="The code that represents relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints taken from [CHI Health Concern Code](https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode)" /> <comment value="The binding strength of this element is [Example](https://www.hl7.org/fhir/terminologies.html#strength), meaning that the Canada Health Infoway Health Concern Code value set provides examples of the types of concepts intended to be included" /> <binding> <strength value="example" /> <description value="Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider." /> <valueSet value="https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode" /> </binding> </element> </differential> </StructureDefinition>