CodeX Implementation Guide: ICAREdata v0.1.2

CodeX Implementation Guide: ICAREdata v0.1.2 FHIR Profiles - Local Development build (v0.1.2). See the Directory of published versions

ServiceRequest

Definitions for obf-ServiceRequest.

1. Basic
Definition

A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

Control0..*
Alternate NamesZ-resource, Extension-resource, Custom-resource
2. Basic.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
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.

3. Basic.meta
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.

Control0..1
TypeMeta
4. Basic.meta.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
5. Basic.meta.extension
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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

SlicingThis element introduces a set of slices on Basic.meta.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
6. sourcesystem
SliceNamesourcesystem
Definition

FHIR: This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. FHIM: Identifies the computer system that created the medical record. This optional field may also be used to indicate that the medical record was originally created by a different organization from the one that is currently storing or utilizing the record in that the assigning authority of the Id could be set to that originating organization. This property is optional, as some systems will assume that all records that it contains originated in that system, however it is anticipated that it will become increasingly commonplace for records from multiple systems and organizations will be comingled in order to provide a complete picture of the patient's health record.

Control0..1
TypeExtension(SourceSystem) (Extension Type: uri)
7. Basic.meta.versionId
Definition

The version specific identifier, as it appears in the version portion of the URL. This values changes when the resource is created, updated, or deleted.

Control0..1
Typeid
Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

8. Basic.meta.lastUpdated
Definition

When the resource last changed - e.g. when the version changed.

Control0..1
Typeinstant
Comments

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant.

9. Basic.meta.profile
Definition

A list of profiles StructureDefinitions that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Control0..*
Typeuri
Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

10. Basic.meta.security
Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Control0..*
BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
The codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable
TypeCoding
Comments

The security labels can be updated without changing the stated version of the resource The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

11. Basic.meta.tag
Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Control0..*
BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
TypeCoding
Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

12. Basic.implicitRules
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.

Control0..1
Typeuri
Is Modifiertrue
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.

13. Basic.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
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).

14. Basic.text
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.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

15. Basic.contained
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.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
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.

16. Basic.extension
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.

Control5..*
TypeExtension
Alternate Namesextensions, user content
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.

SlicingThis element introduces a set of slices on Basic.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
17. status
SliceNamestatus
Definition

A state that relates to the workflow or interpretation of this resource. Certain status values can modify the meaning of the resource, for example, entered-in-error. When a boolean value is used, Status of true indicates the record is active, false means inactive.

Control1..1
TypeExtension(Status) (Extension Type: CodeableConcept)
18. identifier
SliceNameidentifier
Definition

Business identifier or external id for this resource.

Control0..*
TypeExtension(Identifier) (Extension Type: Identifier)
19. subjectofrecord
SliceNamesubjectofrecord
Definition

The subject of a clinical statement, often called the Patient or the Subject. The SubjectOfRecord typically identifies the clinical record in which this statement is contained. If the statement should be in John Doe's patient record, then John Doe is the subject of record. When there is no patient, the SubjectOfRecord can also be a location, group, or other entity that statement pertains to. For example, observations concerning a hospital ward would have a Location as the SubjectOfRecord.

Note that the word 'Subject' is used here in the sense of a person or entity subjected to observations or actions, not subject as in a conceptual topic, like heart disease.

Control1..1
TypeExtension(SubjectOfRecord) (Extension Type: Reference(http://fhir.org/guides/argonaut/StructureDefinition/argo-patient | Practitioner | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Specimen | Location | http://fhir.org/guides/argonaut/StructureDefinition/argo-medication | ResearchSubject))
20. carecontext
SliceNamecarecontext
Definition

The encounter or episode of care

Control0..1
TypeExtension(CareContext) (Extension Type: Reference(Encounter | EpisodeOfCare))
21. Basic.extension-carecontext.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
22. Basic.extension-carecontext.extension
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.

Control0..0
TypeExtension
Alternate Namesextensions, user content
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.

23. Basic.extension-carecontext.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Fixed Valuehttp://mcodeinitiative.org/codex/us/icare/StructureDefinition/obf-CareContext-extension
24. Basic.extension-carecontext.valueReference
Definition

A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Control1..1
TypeReference(Encounter)
25. statementdatetime
SliceNamestatementdatetime
Definition

The point in time when the statement was created.

Control0..1
TypeExtension(StatementDateTime) (Extension Type: dateTime)
26. reasoncode
SliceNamereasoncode
Definition

The explanation or justification for the current item or action, as a code. Reason is a string or CodeableConcept in DSTU2 but in later versions only a CodeableConcept.

Control0..1
TypeExtension(ReasonCode) (Extension Type: CodeableConcept)
27. servicereasonreference
SliceNameservicereasonreference
Definition

Explanation/Justification for service or service

Control0..1
TypeExtension(ServiceReasonReference) (Extension Type: Reference(http://fhir.org/guides/argonaut/StructureDefinition/argo-condition | Observation | DiagnosticReport | DocumentReference))
28. servicebasedon
SliceNameservicebasedon
Definition

The original or initiating plan, proposal, or request.

Control0..*
TypeExtension(ServiceBasedOn) (Extension Type: Reference(ServiceRequest | ProcedureRequest))
29. code
SliceNamecode
Definition

The main type identifier for a lab, procedure, condition, etc., usually drawn from a controlled vocabulary.

Control1..1
TypeExtension(Code) (Extension Type: CodeableConcept)
30. category
SliceNamecategory
Definition

The general type or class of this item.

Control0..*
TypeExtension(Category) (Extension Type: CodeableConcept)
31. requester
SliceNamerequester
Definition

The person or organization originating this referral

Control0..1
TypeExtension(Requester) (Extension Type: Reference(Practitioner | Organization | http://fhir.org/guides/argonaut/StructureDefinition/argo-patient | RelatedPerson | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Basic))
32. requestintent
SliceNamerequestintent
Definition

Indicates the level of authority/intentionality associated with the request and where the request fits into the workflow chain.

Control1..1
TypeExtension(RequestIntent) (Extension Type: CodeableConcept)
33. Basic.extension-requestintent.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
34. Basic.extension-requestintent.extension
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.

Control0..0
TypeExtension
Alternate Namesextensions, user content
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.

35. Basic.extension-requestintent.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Fixed Valuehttp://mcodeinitiative.org/codex/us/icare/StructureDefinition/obf-RequestIntent-extension
36. Basic.extension-requestintent.valueCodeableConcept
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control1..1
BindingThe codes SHALL be taken from request-intent
TypeCodeableConcept
37. expectedperformancetime
SliceNameexpectedperformancetime
Definition

When an action should be done. If the action is a series or recurs (e.g. daily blood sugar testing in the morning) then a Timing can be used to describe the periodicity.

Control0..1
TypeExtension(ExpectedPerformanceTime) (Extension Type: Choice of: dateTime, Period, Timing)
38. expectedperformertype
SliceNameexpectedperformertype
Definition

What type of party should carry out the testing.

Control0..1
TypeExtension(ExpectedPerformerType) (Extension Type: CodeableConcept)
39. expectedperformer
SliceNameexpectedperformer
Definition

Who this request is being addressed to.

Control0..1
TypeExtension(ExpectedPerformer) (Extension Type: Reference(http://fhir.org/guides/argonaut/StructureDefinition/argo-patient | Practitioner | RelatedPerson | Organization | http://fhir.org/guides/argonaut/StructureDefinition/argo-device))
40. prioritycode
SliceNameprioritycode
Definition

An indication of the importance of an action relative to other actions.

Control0..1
TypeExtension(PriorityCode) (Extension Type: Choice of: positiveInt, CodeableConcept)
41. annotation
SliceNameannotation
Definition

An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.

Control0..*
TypeExtension(Annotation) (Extension Type: Annotation)
42. replacesrequest
SliceNamereplacesrequest
Definition

Request(s) replaced by this request

Control0..*
TypeExtension(ReplacesRequest) (Extension Type: Reference(DomainResource))
43. Basic.extension-replacesrequest.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
44. Basic.extension-replacesrequest.extension
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.

Control0..0
TypeExtension
Alternate Namesextensions, user content
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.

45. Basic.extension-replacesrequest.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Fixed Valuehttp://mcodeinitiative.org/codex/us/icare/StructureDefinition/obf-ReplacesRequest-extension
46. Basic.extension-replacesrequest.valueReference-DomainResource
Definition

A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

Control1..1
TypeReference(ServiceRequest)
47. groupidentifier
SliceNamegroupidentifier
Definition

A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier.

Control0..1
TypeExtension(GroupIdentifier) (Extension Type: Identifier)
48. donotperform
SliceNamedonotperform
Definition

A flag, when set to true, indicates that the service/procedure should NOT be performed.

Control0..1
TypeExtension(DoNotPerform) (Extension Type: boolean)
49. servicedetails
SliceNameservicedetails
Definition

A service requested or performed. Additional details and instructions about the service requested or performed. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied.

Control0..*
TypeExtension(ServiceDetails) (Extension Type: CodeableConcept)
50. requestquantity
SliceNamerequestquantity
Definition

An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction).

Control0..1
TypeExtension(RequestQuantity) (Extension Type: Choice of: Quantity, Ratio, Range)
51. requestsubjectofrecord
SliceNamerequestsubjectofrecord
Definition

The subject of the requested service. This is usually limited to a human patient, but can also be requested on groups, devices, or locations (typically for environmental scans).

Control1..1
TypeExtension(RequestSubjectOfRecord) (Extension Type: Reference(http://fhir.org/guides/argonaut/StructureDefinition/argo-patient | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Location))
52. asneeded
SliceNameasneeded
Definition

Preconditions for service, either 'true' indicating to be performed if needed, or a code indicating the pre-condition for performing the service. For example 'pain', 'on flare-up', etc.

Control0..1
TypeExtension(AsNeeded) (Extension Type: Choice of: boolean, CodeableConcept)
53. locationtype
SliceNamelocationtype
Definition

The preferred type of location(s) where the service should happen, in coded or free text form, e.g. at home or nursing day care center.

Control0..*
TypeExtension(LocationType) (Extension Type: CodeableConcept)
54. location
SliceNamelocation
Definition

Services and space and equipment provided for a particular purpose; a building or place that provides a particular service or is used for a particular industry. Could be a clinical site, community site, or a mobile facility.

Control0..*
TypeExtension(Location) (Extension Type: Reference(Location))
55. insurance
SliceNameinsurance
Definition

Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service.

Control0..*
TypeExtension(Insurance) (Extension Type: Reference(Coverage))
56. supportinginformation
SliceNamesupportinginformation
Definition

Additional information to support this request.

Control0..*
TypeExtension(SupportingInformation) (Extension Type: Reference(Resource))
57. specimen
SliceNamespecimen
Definition

A specimen is a substance, physical object, or collection of objects, that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. A specimen may include multiple physical pieces as long as they are considered a single unit within the laboratory workflow. A specimen results from one to many specimen collection procedures, and may be contained in multiple specimen containers. Specimen may have one or more processing activities.

Control0..*
TypeExtension(Specimen) (Extension Type: Reference(Specimen))
58. bodylocation
SliceNamebodylocation
Definition

A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart. Body location is a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases. * Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location. * Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation. * Relation to landmark: The location relative to a landmark is specified by: 1. Establishing the location and type of landmark using a body site code and optional laterality/orientation, and 2. Specifying the direction and distance from the landmark to the body location. Note that BodyLocation is a data type, a reusable structure, not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR's stand-alone BodySite (aka BodyStructure in r4) which 'is not ... intended for describing the type of anatomical location but rather a specific body site on a specific patient' (FHIR 3.5).

Control0..*
TypeExtension(BodyLocation) (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
59. patientinstruction
SliceNamepatientinstruction
Definition

Patient or consumer-oriented instructions.

Control0..1
TypeExtension(PatientInstruction) (Extension Type: string)
60. Basic.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
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.

61. Basic.identifier
Definition

Identifier assigned to the resource for business purposes, outside the context of FHIR.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
62. Basic.code
Definition

Identifies the 'type' of resource - equivalent to the resource name for other resources.

Control1..1
BindingCodes for identifying types of resources not yet defined by FHIR
For example codes, see Basic Resource Types
TypeCodeableConcept
Is Modifiertrue
Requirements

Must be able to distinguish different types of "basic" resources.

Comments

Because resource references will only be able to indicate 'Basic', the type of reference will need to be specified in a Profile identified as part of the resource. Refer to the resource notes section for information on appropriate terminologies for this code.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://mcodeinitiative.org/codex/us/icare/CodeSystem/icare-basic-resource-type"/>
    <code value="obf-ServiceRequest"/>
    <userSelected value="false"/>
  </coding>
</valueCodeableConcept>
63. Basic.subject
Definition

Identifies the patient, practitioner, device or any other resource that is the "focus" of this resource.

Control0..1
TypeReference(Resource)
Requirements

Needed for partitioning the resource by Patient.

Comments

Optional as not all resources potential resources will have subjects. Resources associated with multiple subjects can handle this via extension.

64. Basic.author
Definition

Indicates who was responsible for creating the resource instance.

Control0..1
TypeReference(Practitioner | Patient | RelatedPerson)
Requirements

Needed for partitioning the resource.

65. Basic.created
Definition

Identifies when the resource was first created.

Control0..1
Typedate
Requirements

Allows ordering resource instances by time.