{ "resourceType": "StructureDefinition", "requirements": "To support reporting for any diagnostic report into a clinical data repository.", "constrainedType": "DiagnosticReport", "base": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "meta": { "lastUpdated": "2015-09-22T10:02:49.724+00:00" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 3 } ], "url": "http://hl7.no/fhir/StructureDefinition/LabDiagnosticReportNorway", "name": "LabDiagnosticReportNorway", "status": "draft", "date": "2015-09-22T10:02:49+00:00", "description": "Base StructureDefinition for DiagnosticReport Resource", "fhirVersion": "1.0.1", "mapping": [ { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" } ], "kind": "resource", "abstract": false, "snapshot": { "element": [ { "comments": "This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.", "path": "DiagnosticReport", "short": "A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports", "definition": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.", "alias": [ "Report", "Test", "Result", "Results", "Labs", "Laboratory" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport", "min": 0, "max": "*" }, "type": [ { "code": "DiagnosticReport" } ], "mapping": [ { "identity": "v2", "map": "ORU -> OBR" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" }, { "identity": "w5", "map": "clinical.diagnostics" } ] }, { "path": "DiagnosticReport.identifier", "short": "Id for external references to this report", "definition": "The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider.", "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" ], "min": 0, "max": "0", "base": { "path": "DiagnosticReport.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-51" }, { "identity": "rim", "map": "id" }, { "identity": "w5", "map": "id" } ] }, { "comments": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "path": "DiagnosticReport.identifier.use", "short": "usual | official | temp | secondary (If known)", "definition": "The purpose of this identifier.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/identifier-use" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "comments": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "path": "DiagnosticReport.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 0, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "extensible", "description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/identifier-type" } }, "mapping": [ { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "comments": "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 labelled as UserSelected = true.", "path": "DiagnosticReport.identifier.type.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "path": "DiagnosticReport.identifier.type.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 0, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "path": "DiagnosticReport.identifier.type.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "min": 0, "max": "1", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "path": "DiagnosticReport.identifier.type.coding.code", "short": "Symbol in syntax defined by the system", "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).", "requirements": "Need to refer to a particular code in the system.", "min": 0, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "DiagnosticReport.identifier.type.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.", "path": "DiagnosticReport.identifier.type.coding.userSelected", "short": "If this coding was chosen directly by the user", "definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "comments": "Very often the text is the same as a displayName of one of the codings.", "path": "DiagnosticReport.identifier.type.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.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "exampleUri": "http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri", "path": "DiagnosticReport.identifier.system", "short": "The namespace for the identifier", "definition": "Establishes the namespace in which set of possible id values is unique.", "requirements": "There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "comments": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.", "exampleString": "123456", "path": "DiagnosticReport.identifier.value", "short": "The value that is unique", "definition": "The portion of the identifier typically displayed to the user and which is unique within the context of the system.", "min": 0, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "path": "DiagnosticReport.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "comments": "If the low element is missing, the meaning is that the low boundary is not known.", "path": "DiagnosticReport.identifier.period.start", "short": "Starting time with inclusive boundary", "definition": "The start of the period. The boundary is inclusive.", "min": 0, "max": "1", "base": { "path": "Period.start", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "per-1" ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "DR.1" }, { "identity": "rim", "map": "./low" } ] }, { "comments": "The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has a end value of 2012-02-03.", "path": "DiagnosticReport.identifier.period.end", "short": "End time with inclusive boundary, if not ongoing", "definition": "The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.", "min": 0, "max": "1", "base": { "path": "Period.end", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing", "condition": [ "per-1" ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "DR.2" }, { "identity": "rim", "map": "./high" } ] }, { "comments": "The reference may be just a text description of the assigner.", "path": "DiagnosticReport.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "comments": "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.", "path": "DiagnosticReport.identifier.assigner.reference", "short": "Relative, internal or absolute URL reference", "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.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-1" ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "path": "DiagnosticReport.identifier.assigner.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "This is labeled as \"Is Modifier\" because applications need to take appropriate action if a report is withdrawn.", "path": "DiagnosticReport.status", "short": "registered | partial | final | corrected | appended | cancelled | entered-in-error", "definition": "The status of the diagnostic report as a whole.", "requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "The status of the diagnostic report as a whole.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-report-status" } }, "mapping": [ { "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" } ] }, { "comments": "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.", "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.", "alias": [ "Department", "Sub-department", "service", "discipline" ], "min": 0, "max": "0", "base": { "path": "DiagnosticReport.category", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "Codes for diagnostic service sections.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-service-sections" } }, "mapping": [ { "identity": "v2", "map": "OBR-24" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code" }, { "identity": "w5", "map": "class" } ] }, { "comments": "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 labelled as UserSelected = true.", "path": "DiagnosticReport.category.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "path": "DiagnosticReport.category.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 0, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "path": "DiagnosticReport.category.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "min": 0, "max": "1", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "path": "DiagnosticReport.category.coding.code", "short": "Symbol in syntax defined by the system", "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).", "requirements": "Need to refer to a particular code in the system.", "min": 0, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "DiagnosticReport.category.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.", "path": "DiagnosticReport.category.coding.userSelected", "short": "If this coding was chosen directly by the user", "definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "comments": "Very often the text is the same as a displayName of one of the codings.", "path": "DiagnosticReport.category.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.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "", "path": "DiagnosticReport.code", "short": "Name/Code for this diagnostic report", "definition": "A code or name that describes this diagnostic report.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "preferred", "description": "Codes that describe Diagnostic Reports.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/report-codes" } }, "mapping": [ { "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" } ] }, { "comments": "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 labelled as UserSelected = true.", "path": "DiagnosticReport.code.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 1, "max": "1", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "path": "DiagnosticReport.code.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "path": "DiagnosticReport.code.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "min": 0, "max": "0", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "path": "DiagnosticReport.code.coding.code", "short": "Symbol in syntax defined by the system", "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).", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "DiagnosticReport.code.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 1, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.", "path": "DiagnosticReport.code.coding.userSelected", "short": "If this coding was chosen directly by the user", "definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "0", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "comments": "Very often the text is the same as a displayName of one of the codings.", "path": "DiagnosticReport.code.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.", "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": "0", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "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.", "requirements": "SHALL know the subject context.", "alias": [ "Patient" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.subject", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabPatientNorway", "aggregation": [ "contained" ] } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3 (no HL7 v2 mapping for Group or Device)" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "who.focus" } ] }, { "path": "DiagnosticReport.encounter", "short": "Health care event when test ordered", "definition": "The link to the health care event (encounter) when the order was made.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" }, { "identity": "w5", "map": "context" } ] }, { "comments": "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.", "path": "DiagnosticReport.encounter.reference", "short": "Relative, internal or absolute URL reference", "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.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-1" ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "path": "DiagnosticReport.encounter.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.", "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.", "requirements": "Need to know where in the patient history to file/present this report.", "alias": [ "Observation time", "Effective Time" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.effective[x]", "min": 1, "max": "1" }, "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-7" }, { "identity": "rim", "map": "effectiveTime" }, { "identity": "w5", "map": "when.done" } ] }, { "comments": "May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.", "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.", "requirements": "Clinicians need to be able to check the date that the report was released.", "alias": [ "Date Created", "Date published", "Date Issued" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.issued", "min": 1, "max": "1" }, "type": [ { "code": "instant" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-22" }, { "identity": "rim", "map": "participation[typeCode=VRF or AUT].time" }, { "identity": "w5", "map": "when.recorded" } ] }, { "comments": "This is not necessarily the source of the atomic data items. It is the entity that takes responsibility for the clinical report.", "path": "DiagnosticReport.performer", "short": "Responsible Diagnostic Service", "definition": "The diagnostic service that is responsible for issuing the report.", "requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.", "alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.performer", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabOrganizationNorway", "aggregation": [ "contained" ] }, { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabPractitionerNorway", "aggregation": [ "contained" ] } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": "participation[typeCode=AUT].role[classCode=ASSIGN].scoper" }, { "identity": "w5", "map": "who.witness" } ] }, { "comments": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.", "path": "DiagnosticReport.request", "short": "What was requested", "definition": "Details concerning a test or procedure requested.", "requirements": "Need to be able to track completion of requests based on reports issued and also to report what diagnostic tests were requested (not always the same as what is delivered).", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.request", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/DiagnosticOrder" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ], "mapping": [ { "identity": "v2", "map": "ORC? OBR-2/3?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=FLFS].target" } ] }, { "comments": "If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per Observation or group.", "path": "DiagnosticReport.specimen", "short": "Specimens this report is based on", "definition": "Details about the specimens on which this diagnostic report is based.", "requirements": "Need to be able to report information about the collected specimens on which the report is based.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.specimen", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "comments": "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.", "path": "DiagnosticReport.specimen.reference", "short": "Relative, internal or absolute URL reference", "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.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-1" ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "path": "DiagnosticReport.specimen.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "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\").", "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": 1, "max": "*", "base": { "path": "DiagnosticReport.result", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabObservationNorway" } ], "mapping": [ { "identity": "v2", "map": "OBXs" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "comments": "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.", "path": "DiagnosticReport.result.reference", "short": "Relative, internal or absolute URL reference", "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.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-1" ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "path": "DiagnosticReport.result.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "ImagingStudy and ImageObjectStudy 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.", "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.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.imagingStudy", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ImagingObjectSelection" } ], "mapping": [ { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]" } ] }, { "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": "0", "base": { "path": "DiagnosticReport.image", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "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.", "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" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] }, { "path": "DiagnosticReport.image.link", "short": "Reference to the image source", "definition": "Reference to the image source.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.image.link", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Media" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".value.reference" } ] }, { "comments": "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.", "path": "DiagnosticReport.image.link.reference", "short": "Relative, internal or absolute URL reference", "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.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ref-1" ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "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.", "path": "DiagnosticReport.image.link.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "Typically, a report is either [all data, no narrative (e.g. Core lab)] or [a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density)], or [all narrative (e.g. typical imaging report, histopathology)]. In all of these cases, the narrative goes in \"text\".", "path": "DiagnosticReport.conclusion", "short": "Clinical Interpretation of test results", "definition": "Concise and clinically contextualized narrative interpretation of the diagnostic report.", "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" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)" } ] }, { "path": "DiagnosticReport.codedDiagnosis", "short": "Codes for the conclusion", "definition": "Codes for the conclusion.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.codedDiagnosis", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Diagnoses codes provided as adjuncts to the report.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/clinical-findings" } }, "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)" } ] }, { "comments": "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 labelled as UserSelected = true.", "path": "DiagnosticReport.codedDiagnosis.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "path": "DiagnosticReport.codedDiagnosis.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 0, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "path": "DiagnosticReport.codedDiagnosis.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "min": 0, "max": "1", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "path": "DiagnosticReport.codedDiagnosis.coding.code", "short": "Symbol in syntax defined by the system", "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).", "requirements": "Need to refer to a particular code in the system.", "min": 0, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "DiagnosticReport.codedDiagnosis.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.", "path": "DiagnosticReport.codedDiagnosis.coding.userSelected", "short": "If this coding was chosen directly by the user", "definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "comments": "Very often the text is the same as a displayName of one of the codings.", "path": "DiagnosticReport.codedDiagnosis.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.", "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" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "\"application/pdf\" is recommended as the most reliable and interoperable in this context.", "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.", "requirements": "Gives Laboratory the ability to provide its own fully formatted report for clinical fidelity.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.presentedForm", "min": 0, "max": "*" }, "type": [ { "code": "Attachment" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "text (type=ED)" } ] }, { "exampleCode": "text/plain; charset=UTF-8, image/png", "path": "DiagnosticReport.presentedForm.contentType", "short": "Mime type of the content, with charset etc.", "definition": "Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.", "requirements": "Processors of the data need to be able to know how to interpret the data.", "min": 0, "max": "1", "base": { "path": "Attachment.contentType", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "The mime type of an attachment. Any valid mime type is allowed.", "valueSetUri": "http://www.rfc-editor.org/bcp/bcp13.txt" }, "mapping": [ { "identity": "v2", "map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used" }, { "identity": "rim", "map": "./mediaType, ./charset" } ] }, { "exampleCode": "en-AU", "path": "DiagnosticReport.presentedForm.language", "short": "Human language of the content (BCP-47)", "definition": "The human language of the content. The value can be any valid value according to BCP 47.", "requirements": "Users need to be able to choose between the languages in a set of attachments.", "min": 0, "max": "1", "base": { "path": "Attachment.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "A human language.", "valueSetUri": "http://tools.ietf.org/html/bcp47" }, "mapping": [ { "identity": "rim", "map": "./language" } ] }, { "comments": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.", "path": "DiagnosticReport.presentedForm.data", "short": "Data inline, base64ed", "definition": "The actual data of the attachment - a sequence of bytes. In XML, represented using base64.", "requirements": "The data needs to able to be transmitted inline.", "min": 0, "max": "1", "base": { "path": "Attachment.data", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ED.5" }, { "identity": "rim", "map": "./data" } ] }, { "comments": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.", "exampleUri": "http://www.acme.com/logo-small.png", "path": "DiagnosticReport.presentedForm.url", "short": "Uri where the data can be found", "definition": "An alternative location where the data can be accessed.", "requirements": "The data needs to be transmitted by reference.", "min": 0, "max": "1", "base": { "path": "Attachment.url", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "RP.1+RP.2 - if they refer to a URL (see v2.6)" }, { "identity": "rim", "map": "./reference/literal" } ] }, { "comments": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.", "path": "DiagnosticReport.presentedForm.size", "short": "Number of bytes of content (if url provided)", "definition": "The number of bytes of data that make up this attachment.", "requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.", "min": 0, "max": "1", "base": { "path": "Attachment.size", "min": 0, "max": "1" }, "type": [ { "code": "unsignedInt" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A (needs data type R3 proposal)" } ] }, { "path": "DiagnosticReport.presentedForm.hash", "short": "Hash of the data (sha-1, base64ed)", "definition": "The calculated hash of the data using SHA-1. Represented using base64.", "requirements": "Included so that applications can verify that the contents of a location have not changed and so that a signature of the content can implicitly sign the content of an image without having to include the data in the instance or reference the url in the signature.", "min": 0, "max": "1", "base": { "path": "Attachment.hash", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]" } ] }, { "exampleString": "Official Corporate Logo", "path": "DiagnosticReport.presentedForm.title", "short": "Label to display in place of the data", "definition": "A label or set of text to display in place of the data.", "requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.", "min": 0, "max": "1", "base": { "path": "Attachment.title", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "./title/data" } ] }, { "path": "DiagnosticReport.presentedForm.creation", "short": "Date attachment was first created", "definition": "The date that the attachment was first created.", "requirements": "This is often tracked as an integrity issue for use of the attachment.", "min": 0, "max": "1", "base": { "path": "Attachment.creation", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A (needs data type R3 proposal)" } ] } ] }, "differential": { "element": [ { "comments": "This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.", "path": "DiagnosticReport", "short": "A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports", "definition": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.", "alias": [ "Report", "Test", "Result", "Results", "Labs", "Laboratory" ], "min": 0, "max": "*", "base": { "path": "DiagnosticReport", "min": 0, "max": "*" }, "type": [ { "code": "DiagnosticReport" } ], "mapping": [ { "identity": "v2", "map": "ORU -> OBR" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" }, { "identity": "w5", "map": "clinical.diagnostics" } ] }, { "path": "DiagnosticReport.identifier", "short": "Id for external references to this report", "definition": "The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider.", "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" ], "min": 0, "max": "0", "base": { "path": "DiagnosticReport.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-51" }, { "identity": "rim", "map": "id" }, { "identity": "w5", "map": "id" } ] }, { "comments": "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.", "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.", "alias": [ "Department", "Sub-department", "service", "discipline" ], "min": 0, "max": "0", "base": { "path": "DiagnosticReport.category", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "Codes for diagnostic service sections.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-service-sections" } }, "mapping": [ { "identity": "v2", "map": "OBR-24" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code" }, { "identity": "w5", "map": "class" } ] }, { "comments": "", "path": "DiagnosticReport.code", "short": "Name/Code for this diagnostic report", "definition": "A code or name that describes this diagnostic report.", "min": 1, "max": "1", "base": { "path": "DiagnosticReport.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "preferred", "description": "Codes that describe Diagnostic Reports.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/report-codes" } }, "mapping": [ { "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" } ] }, { "comments": "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 labelled as UserSelected = true.", "path": "DiagnosticReport.code.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 1, "max": "1", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "path": "DiagnosticReport.code.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "path": "DiagnosticReport.code.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "min": 0, "max": "0", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "path": "DiagnosticReport.code.coding.code", "short": "Symbol in syntax defined by the system", "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).", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "DiagnosticReport.code.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 1, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.", "path": "DiagnosticReport.code.coding.userSelected", "short": "If this coding was chosen directly by the user", "definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "0", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "comments": "Very often the text is the same as a displayName of one of the codings.", "path": "DiagnosticReport.code.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.", "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": "0", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "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" } ] }, { "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.", "requirements": "SHALL know the subject context.", "alias": [ "Patient" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.subject", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabPatientNorway", "aggregation": [ "contained" ] } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3 (no HL7 v2 mapping for Group or Device)" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "who.focus" } ] }, { "path": "DiagnosticReport.encounter", "short": "Health care event when test ordered", "definition": "The link to the health care event (encounter) when the order was made.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" }, { "identity": "w5", "map": "context" } ] }, { "comments": "If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.", "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.", "requirements": "Need to know where in the patient history to file/present this report.", "alias": [ "Observation time", "Effective Time" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.effective[x]", "min": 1, "max": "1" }, "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-7" }, { "identity": "rim", "map": "effectiveTime" }, { "identity": "w5", "map": "when.done" } ] }, { "comments": "This is not necessarily the source of the atomic data items. It is the entity that takes responsibility for the clinical report.", "path": "DiagnosticReport.performer", "short": "Responsible Diagnostic Service", "definition": "The diagnostic service that is responsible for issuing the report.", "requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.", "alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company" ], "min": 1, "max": "1", "base": { "path": "DiagnosticReport.performer", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabOrganizationNorway", "aggregation": [ "contained" ] }, { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabPractitionerNorway", "aggregation": [ "contained" ] } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PRT-8 (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": "participation[typeCode=AUT].role[classCode=ASSIGN].scoper" }, { "identity": "w5", "map": "who.witness" } ] }, { "comments": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.", "path": "DiagnosticReport.request", "short": "What was requested", "definition": "Details concerning a test or procedure requested.", "requirements": "Need to be able to track completion of requests based on reports issued and also to report what diagnostic tests were requested (not always the same as what is delivered).", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.request", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/DiagnosticOrder" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ], "mapping": [ { "identity": "v2", "map": "ORC? OBR-2/3?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=FLFS].target" } ] }, { "comments": "If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per Observation or group.", "path": "DiagnosticReport.specimen", "short": "Specimens this report is based on", "definition": "Details about the specimens on which this diagnostic report is based.", "requirements": "Need to be able to report information about the collected specimens on which the report is based.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.specimen", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" } ] }, { "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\").", "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": 1, "max": "*", "base": { "path": "DiagnosticReport.result", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.no/fhir/StructureDefinition/LabObservationNorway" } ], "mapping": [ { "identity": "v2", "map": "OBXs" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "comments": "ImagingStudy and ImageObjectStudy 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.", "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.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.imagingStudy", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ImagingObjectSelection" } ], "mapping": [ { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]" } ] }, { "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": "0", "base": { "path": "DiagnosticReport.image", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "path": "DiagnosticReport.codedDiagnosis", "short": "Codes for the conclusion", "definition": "Codes for the conclusion.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.codedDiagnosis", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Diagnoses codes provided as adjuncts to the report.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/clinical-findings" } }, "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)" } ] }, { "comments": "\"application/pdf\" is recommended as the most reliable and interoperable in this context.", "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.", "requirements": "Gives Laboratory the ability to provide its own fully formatted report for clinical fidelity.", "min": 0, "max": "0", "base": { "path": "DiagnosticReport.presentedForm", "min": 0, "max": "*" }, "type": [ { "code": "Attachment" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "text (type=ED)" } ] } ] } }