HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU Ballot 1

HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU Ballot 1 - Local Development build (v0.9.1). See the Directory of published versions

ComprehensiveMetabolic2000SerumOrPlasmaPanel

Definitions for obf-lab-ComprehensiveMetabolic2000SerumOrPlasmaPanel.

1. DiagnosticReport
Definition

Represents a comprehensive metabolic 2000 panel (CMP) from serum or plasma, which measures various components such as glucose, electrolytes, kidney function, and liver function. The components of this panel are not entirely standardized, so the definition of the CMP includes tests that are optional, or performed by certain laboratories but not others. Therefore, instances typically will include a subset of the listed panel members.

Control0..*
Alternate NamesReport, Test, Result, Results, Labs, Laboratory, Lab Result, Lab Report
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.

InvariantsDefined on this element
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.div.exists())
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
2. DiagnosticReport.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.

3. DiagnosticReport.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control0..1
TypeMeta
4. DiagnosticReport.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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

5. DiagnosticReport.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHOULD be taken from CommonLanguages
Max Binding: AllLanguages
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).

6. DiagnosticReport.text
Definition

A human-readable narrative that contains a summary of the resource and can 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
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

7. DiagnosticReport.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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

8. DiagnosticReport.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. 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 can 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.

9. DiagnosticReport.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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

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.

10. DiagnosticReport.identifier
Definition

Identifiers assigned to this report by the performer or other systems.

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

Alternate NamesReportID, Filler ID, Placer ID
Comments

Usually assigned by the Information System of the diagnostic service provider (filler id).

11. DiagnosticReport.basedOn
Definition

Details concerning a service requested.

Control0..*
TypeReference(ServiceRequest | USCoreMedicationRequestProfile)
Requirements

This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

Alternate NamesRequest
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.

12. DiagnosticReport.status
Definition

The status of the diagnostic report.

Control1..1
BindingThe codes SHALL be taken from DiagnosticReportStatus
Typecode
Is Modifiertrue
Must Supporttrue
Requirements

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

13. DiagnosticReport.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.

Control1..1
BindingCodes for diagnostic service sections.
For example codes, see DiagnosticServiceSectionCodes
TypeCodeableConcept
Must Supporttrue
Alternate NamesDepartment, Sub-department, Service, Discipline
Comments

Multiple categories are allowed using various categorization schemes. 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.

14. DiagnosticReport.category:lab
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.

Control1..1
BindingCodes for diagnostic service sections.
For example codes, see DiagnosticServiceSectionCodes
TypeCodeableConcept
Must Supporttrue
Alternate NamesDepartment, Sub-department, Service, Discipline
Comments

Multiple categories are allowed using various categorization schemes. 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.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
    <code value="LAB"/>
  </coding>
</valueCodeableConcept>
15. DiagnosticReport.code
Definition

The test, panel or battery that was ordered.

Control1..1
BindingLOINC codes
The codes SHALL be taken from US Core Diagnostic Report Laboratory Codes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Alternate NamesType
Comments

UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists.

16. DiagnosticReport.code.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
17. DiagnosticReport.code.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.

18. DiagnosticReport.code.coding
Definition

A reference to a code defined by a terminology system.

Control1..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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 labeled as UserSelected = true.

19. DiagnosticReport.code.coding:Fixed_24323-8
Definition

Comprehensive metabolic 2000 panel - Serum or Plasma

Control1..1
TypeCoding
20. DiagnosticReport.code.coding:Fixed_24323-8.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
21. DiagnosticReport.code.coding:Fixed_24323-8.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.

22. DiagnosticReport.code.coding:Fixed_24323-8.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Requirements

Need to be unambiguous about the source of the definition of the symbol.

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 reference to some definition that establishes the system clearly and unambiguously.

Fixed Valuehttp://loinc.org
23. DiagnosticReport.code.coding:Fixed_24323-8.version
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.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
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.

24. DiagnosticReport.code.coding:Fixed_24323-8.code
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).

Control0..1
Typecode
Requirements

Need to refer to a particular code in the system.

Fixed Value24323-8
25. DiagnosticReport.code.coding:Fixed_24323-8.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

26. DiagnosticReport.code.coding:Fixed_24323-8.userSelected
Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
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.

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.

27. DiagnosticReport.code.text
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.

Control0..1
Typestring
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.

Comments

Very often the text is the same as a displayName of one of the codings.

28. DiagnosticReport.subject
Definition

The subject of an observation.

Control1..1
TypeReference(Patient)
Must Supporttrue
Requirements

SHALL know the subject context.

Alternate NamesPatient
29. DiagnosticReport.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.

Control0..1
TypeReference(USCoreEncounterProfile)
Requirements

Links the request to the Encounter context.

Alternate NamesContext
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

30. DiagnosticReport.effective[x]
Definition

This is the Specimen Collection Datetime or Period which is the physically relevent dateTime for laboratory tests.

Control1..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

Need to know where in the patient history to file/present this report.

Alternate NamesObservation time, Effective Time, Occurrence
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.

31. DiagnosticReport.issued
Definition

The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.

Control1..1
Typeinstant
Must Supporttrue
Requirements

Clinicians need to be able to check the date that the report was released.

Alternate NamesDate published, Date Issued, Date Verified
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.

32. DiagnosticReport.performer
Definition

The diagnostic service that is responsible for issuing the report.

Control0..1
TypeReference(USCorePractitionerProfile | USCoreOrganizationProfile)
Must Supporttrue
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.

Alternate NamesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director
Comments

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

33. DiagnosticReport.resultsInterpreter
Definition

The practitioner or organization that is responsible for the report's conclusions and interpretations.

Control0..1
TypeReference(USCorePractitionerProfile | USCoreOrganizationProfile)
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.

Alternate NamesAnalyzed by, Reported by
Comments

Might not be the same entity that takes responsibility for the clinical report.

34. DiagnosticReport.specimen
Definition

Details about the specimens on which this diagnostic report is based.

Control0..*
TypeReference(Specimen)
Requirements

Need to be able to report information about the collected specimens on which the report is based.

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.

35. DiagnosticReport.result
Definition

A coded finding based on a specimen, usually collected from a patient (but possibly from a location).

Control0..*
TypeReference(LaboratoryObservation)
Must Supporttrue
Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
Comments

Observations can contain observations.

InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
36. DiagnosticReport.result:obf-lab-GlobulinMCncPtSerQnCalculatedLabObs
Definition

Globulin [Mass/​volume] in Serum by calculation

Control0..1
TypeReference(GlobulinMCncPtSerQnCalculatedLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
37. DiagnosticReport.result:obf-lab-AlanineAminotransferaseCCncPtSerPlasQnLabObs
Definition

Alanine aminotransferase [Enzymatic activity/​volume] in Serum or Plasma

Control0..1
TypeReference(AlanineAminotransferaseCCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
38. DiagnosticReport.result:obf-lab-AlbuminMCncPtSerPlasQnLabObs
Definition

Albumin [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(AlbuminMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
39. DiagnosticReport.result:obf-lab-AlbuminGlobulinMRtoPtSerPlasQnLabObs
Definition

Albumin/​Globulin [Mass Ratio] in Serum or Plasma

Control0..1
TypeReference(AlbuminGlobulinMRtoPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
40. DiagnosticReport.result:obf-lab-CalciumMCncPtSerPlasQnLabObs
Definition

Calcium [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(CalciumMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
41. DiagnosticReport.result:obf-lab-AspartateAminotransferaseCCncPtSerPlasQnLabObs
Definition

Aspartate aminotransferase [Enzymatic activity/​volume] in Serum or Plasma

Control0..1
TypeReference(AspartateAminotransferaseCCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
42. DiagnosticReport.result:obf-lab-BilirubinMCncPtSerPlasQnLabObs
Definition

Bilirubin.total [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(BilirubinMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
43. DiagnosticReport.result:obf-lab-CarbonDioxideSCncPtSerPlasQnLabObs
Definition

Carbon dioxide, total [Moles/​volume] in Serum or Plasma

Control0..1
TypeReference(CarbonDioxideSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
44. DiagnosticReport.result:obf-lab-ChlorideSCncPtSerPlasQnLabObs
Definition

Chloride [Moles/​volume] in Serum or Plasma

Control0..1
TypeReference(ChlorideSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
45. DiagnosticReport.result:obf-lab-CreatinineMCncPtSerPlasQnLabObs
Definition

Creatinine [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(CreatinineMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
46. DiagnosticReport.result:obf-lab-GlucoseMCncPtSerPlasQnLabObs
Definition

Glucose [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(GlucoseMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
47. DiagnosticReport.result:obf-lab-PotassiumSCncPtSerPlasQnLabObs
Definition

Potassium [Moles/​volume] in Serum or Plasma

Control0..1
TypeReference(PotassiumSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
48. DiagnosticReport.result:obf-lab-ProteinMCncPtSerPlasQnLabObs
Definition

Protein [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(ProteinMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
49. DiagnosticReport.result:obf-lab-SodiumSCncPtSerPlasQnLabObs
Definition

Sodium [Moles/​volume] in Serum or Plasma

Control0..1
TypeReference(SodiumSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
50. DiagnosticReport.result:obf-lab-UreaNitrogenMCncPtSerPlasQnLabObs
Definition

Urea nitrogen [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(UreaNitrogenMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
51. DiagnosticReport.result:obf-lab-UreaNitrogenCreatinineMRtoPtSerPlasQnLabObs
Definition

Urea nitrogen/​Creatinine [Mass Ratio] in Serum or Plasma

Control0..1
TypeReference(UreaNitrogenCreatinineMRtoPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
52. DiagnosticReport.result:obf-lab-AlkalinePhosphataseCCncPtSerPlasQnLabObs
Definition

Alkaline phosphatase [Enzymatic activity/​volume] in Serum or Plasma

Control0..1
TypeReference(AlkalinePhosphataseCCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
53. DiagnosticReport.result:obf-lab-GFR173sqMPredArVRatPtSerPlasQnMDRDLabObs
Definition

Glomerular filtration rate/​1.73 sq M.predicted [Volume Rate/​Area] in Serum or Plasma by Creatinine-based formula (MDRD). Units are optional.

Control0..1
TypeReference(GFR173sqMPredArVRatPtSerPlasQnMDRDLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
54. DiagnosticReport.result:obf-lab-GFR173sqMPredFemaleArVRatPtSerPlasBldQnMDRDLabObs
Definition

Glomerular filtration rate/​1.73 sq M predicted among females [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Control0..1
TypeReference(GFR173sqMPredFemaleArVRatPtSerPlasBldQnMDRDLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
55. DiagnosticReport.result:obf-lab-GFR173sqMPredNonBlackArVRatPtSerPlasBldQnMDRDLabObs
Definition

Glomerular filtration rate/​1.73 sq M predicted among non-blacks [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Control0..1
TypeReference(GFR173sqMPredNonBlackArVRatPtSerPlasBldQnMDRDLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
56. DiagnosticReport.result:obf-lab-GFR173sqMPredBlackArVRatPtSerPlasBldQnMDRDLabObs
Definition

Glomerular filtration rate/​1.73 sq M predicted among blacks [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Control0..1
TypeReference(GFR173sqMPredBlackArVRatPtSerPlasBldQnMDRDLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
57. DiagnosticReport.result:obf-lab-BilirubinDirectMCncPtSerPlasQnLabObs
Definition

Bilirubin.direct [Mass/​volume] in Serum or Plasma

Control0..1
TypeReference(BilirubinDirectMCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
58. DiagnosticReport.result:obf-lab-BicarbonateSCncPtSerPlasQnLabObs
Definition

Bicarbonate [Moles/​volume] in Serum or Plasma

Control0..1
TypeReference(BicarbonateSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
59. DiagnosticReport.result:obf-lab-AniongapSCncPtSerPlasQnLabObs
Definition

Anion gap in Serum or Plasma. Units are optional but if provided, must be in mmol/L.

Control0..1
TypeReference(AniongapSCncPtSerPlasQnLabObs)
Must Supporttrue
Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())
60. DiagnosticReport.imagingStudy
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.

Control0..*
TypeReference(ImagingStudy)
Comments

ImagingStudy 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.

61. DiagnosticReport.media
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).

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Many diagnostic services include images in the report as part of their service.

Alternate NamesDICOM, Slides, Scans
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. DiagnosticReport.media.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
63. DiagnosticReport.media.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.

64. DiagnosticReport.media.modifierExtension
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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
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.

65. DiagnosticReport.media.comment
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.

Control0..1
Typestring
Requirements

The provider of the report should make a comment about each image included in the report.

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.

66. DiagnosticReport.media.link
Definition

Reference to the image source.

Control1..1
TypeReference(Media)
67. DiagnosticReport.conclusion
Definition

Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.

Control0..1
Typestring
Requirements

Need to be able to provide a conclusion that is not lost among the basic result data.

Alternate NamesReport
68. DiagnosticReport.conclusionCode
Definition

One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.

Control0..*
BindingDiagnosis codes provided as adjuncts to the report.
For example codes, see SNOMEDCTClinicalFindings
TypeCodeableConcept
69. DiagnosticReport.presentedForm
Definition

Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.

Control0..*
TypeAttachment
Must Supporttrue
Requirements

Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.

Comments

"application/pdf" is recommended as the most reliable and interoperable in this context.

InvariantsDefined on this element
us-core-7: DiagnosticReport.result or DiagnosticReport.presentedForm or both SHALL be present. (: result.exists() or presentedForm.exists())