{ "resourceType": "StructureDefinition", "requirements": "To support reporting for any diagnostic report into a clinical data repository.", "base": "http://hl7.org/fhir/StructureDefinition/DomainResource", "id": "spark34", "meta": { "versionId": "spark34", "lastUpdated": "2015-10-02T11:53:04.687+00:00" }, "text": { "status": "generated", "div": "
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\"DiagnosticReportDomainResourceA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
\".\"\".\"\".\"identifierΣ0..*IdentifierId for external references to this report
\".\"\".\"\".\"status?! Σ1..1coderegistered | partial | final | corrected | appended | cancelled | entered-in-error\n
DiagnosticReportStatus (\n Required)\n
\".\"\".\"\".\"categoryΣ0..1CodeableConceptService category\n
Diagnostic Service Section Codes (\n Example)\n
\".\"\".\"\".\"codeΣ1..1CodeableConceptName/Code for this diagnostic report\n
LOINC Diagnostic Report Codes (\n Preferred)\n
\".\"\".\"\".\"subjectΣ1..1Reference(\n Patient | \n Group | \n Device | \n Location)\n The subject of the report, usually, but not always, the patient
\".\"\".\"\".\"encounterΣ0..1Reference(\n Encounter)\n Health care event when test ordered
\".\"\".\"\".\"effective[x]Σ1..1Clinically Relevant time/time-period for report
\".\"\".\"\".\"\".\"effectiveDateTimedateTime
\".\"\".\"\".\"\".\"effectivePeriodPeriod
\".\"\".\"\".\"issuedΣ1..1instantDateTime this version was released
\".\"\".\"\".\"performerΣ1..1Reference(\n Practitioner | \n Organization)\n Responsible Diagnostic Service
\".\"\".\"\".\"request0..*Reference(\n DiagnosticOrder | \n ProcedureRequest | \n ReferralRequest)\n What was requested
\".\"\".\"\".\"specimen0..*Reference(\n Specimen)\n Specimens this report is based on
\".\"\".\"\".\"result0..*Reference(\n Observation)\n Observations - simple, or complex nested groups
\".\"\".\"\".\"imagingStudy0..*Reference(\n ImagingStudy | \n ImagingObjectSelection)\n Reference to full details of imaging associated with the diagnostic report
\".\"\".\"\".\"imageΣ0..*BackboneElementKey images associated with this report
\".\"\".\"\".\"\".\"comment0..1stringComment about the image (e.g. explanation)
\".\"\".\"\".\"\".\"linkΣ1..1Reference(\n Media)\n Reference to the image source
\".\"\".\"\".\"conclusion0..1stringClinical Interpretation of test results
\".\"\".\"\".\"codedDiagnosis0..*CodeableConceptCodes for the conclusion\n
SNOMED CT Clinical Findings (\n Example)\n
\".\"\".\"\".\"presentedForm0..*AttachmentEntire report as issued

\"doco\" Documentation for this format\n
" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 3 } ], "url": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "name": "DiagnosticReport", "status": "draft", "date": "2015-09-22T03:47:23+00:00", "publisher": "Health Level Seven International (Orders and Observations)", "contact": [ { "telecom": [ { "system": "other", "value": "http://hl7.org/fhir" } ] }, { "telecom": [ { "system": "other", "value": "http://www.hl7.org/Special/committees/orders/index.cfm" } ] } ], "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": "*", "type": [ { "code": "DomainResource" } ], "mapping": [ { "identity": "v2", "map": "ORU -> OBR" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" }, { "identity": "w5", "map": "clinical.diagnostics" } ] }, { "comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.", "path": "DiagnosticReport.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "min": 0, "max": "1", "type": [ { "code": "id" } ], "isSummary": true }, { "path": "DiagnosticReport.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min": 0, "max": "1", "type": [ { "code": "Meta" } ], "isSummary": true }, { "comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.", "path": "DiagnosticReport.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.", "min": 0, "max": "1", "type": [ { "code": "uri" } ], "isModifier": true, "isSummary": true }, { "comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "path": "DiagnosticReport.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A human language.", "valueSetUri": "http://tools.ietf.org/html/bcp47" } }, { "comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.", "path": "DiagnosticReport.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.", "path": "DiagnosticReport.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "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.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "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.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 resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "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": "*", "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 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", "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": "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" } ] }, { "path": "DiagnosticReport.code", "short": "Name/Code for this diagnostic report", "definition": "A code or name that describes this diagnostic report.", "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" } ] }, { "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Group" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "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": "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", "type": [ { "code": "dateTime" }, { "code": "Period" } ], "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", "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "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": "*", "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": "*", "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": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "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": "*", "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": "*", "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "path": "DiagnosticReport.image.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "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.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "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": "*", "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", "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Media" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".value.reference" } ] }, { "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", "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": "*", "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": "*", "type": [ { "code": "Attachment" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "text (type=ED)" } ] } ] }, "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": "*", "type": [ { "code": "DomainResource" } ], "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": "*", "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 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", "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": "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" } ] }, { "path": "DiagnosticReport.code", "short": "Name/Code for this diagnostic report", "definition": "A code or name that describes this diagnostic report.", "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" } ] }, { "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Group" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "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": "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", "type": [ { "code": "dateTime" }, { "code": "Period" } ], "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", "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "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": "*", "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": "*", "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": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "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": "*", "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": "*", "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX?" }, { "identity": "rim", "map": "outboundRelationship[typeCode=COMP].target" } ] }, { "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", "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", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Media" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".value.reference" } ] }, { "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", "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": "*", "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": "*", "type": [ { "code": "Attachment" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "text (type=ED)" } ] } ] } }