HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE), v0.9.1

HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE), v0.9.1 FHIR Profiles - Local Development build (v0.9.1). See the Directory of published versions

DiagnosticReport

 

The official URL for this profile is:

http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-DiagnosticReport

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.

This profile builds on DiagnosticReport.

This profile was published on Wed Oct 23 00:00:00 EDT 2019 as a draft by The MITRE Corporation.

Summary

Mandatory: 0 element (1 nested mandatory element)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.DiagnosticReport maps to DiagnosticReport:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.extension
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  Status maps to status
  Code maps to code
  Category maps to category
  ObservationSubjectOfRecord maps to subject
  CareContext maps to encounter
  RelevantTime maps to effective[x]
  StatementDateTime maps to issued
  DiagnosticReportPerformer maps to performer
  ResultsInterpreter maps to extension
  Specimen maps to specimen
  Observation maps to result (slice on = target.reference.resolve(); slice on type = profile; slice strategy = includes)
  MediaIncluded.CommentOrDescription maps to image.comment
  MediaIncluded.Media maps to image.link
  ConclusionText maps to conclusion
  ConclusionCode maps to codedDiagnosis
  PresentedForm maps to presentedForm

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport obf-DiagnosticReport
... meta
.... extension Slice: Unordered, Open by value:url
.... obf-SourceSystem-extension 0..1uriSourceSystem
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-SourceSystem-extension
... extension Slice: Unordered, Open by value:url
... obf-ResultsInterpreter-extension 0..1Reference(Practitioner | Organization)ResultsInterpreter
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-ResultsInterpreter-extension
... obf-BasedOn-extension 0..*Reference(Basic | ReferralRequest | obf-ProcedureRequest | obf-MedicationRequest | obf-CarePlan)BasedOn
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-BasedOn-extension
... category 1..1
... subject Reference(obf-Patient | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Location)The subject of an observation
... result Reference(obf-Observation)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*obf-DiagnosticReport
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... obf-SourceSystem-extension 0..1uriSourceSystem
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-SourceSystem-extension
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ0..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: (unbound) (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: http://tools.ietf.org/html/bcp47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... obf-ResultsInterpreter-extension 0..1Reference(Practitioner | Organization)ResultsInterpreter
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-ResultsInterpreter-extension
... obf-BasedOn-extension 0..*Reference(Basic | ReferralRequest | obf-ProcedureRequest | obf-MedicationRequest | obf-CarePlan)BasedOn
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-BasedOn-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierId for external references to this report
... status ?!Σ1..1coderegistered | partial | final | corrected | appended | cancelled | entered-in-error
Binding: DiagnosticReportStatus (required)
... category Σ1..1CodeableConceptService category
Binding: Diagnostic Service Section Codes (example)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred)
... subject Σ1..1Reference(obf-Patient | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Location)The subject of an observation
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Clinically Relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ1..1instantDateTime this version was released
... performer Σ1..1Reference(Practitioner | Organization)Responsible Diagnostic Service
... request 0..*Reference(DiagnosticOrder | ProcedureRequest | ReferralRequest)What was requested
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(obf-Observation)Observations - simple, or complex nested groups
... imagingStudy 0..*Reference(ImagingStudy | ImagingObjectSelection)Reference to full details of imaging associated with the diagnostic report
... image Σ0..*BackboneElementKey images associated with this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis 0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (example)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Summary

Mandatory: 0 element (1 nested mandatory element)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.DiagnosticReport maps to DiagnosticReport:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.extension
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  Status maps to status
  Code maps to code
  Category maps to category
  ObservationSubjectOfRecord maps to subject
  CareContext maps to encounter
  RelevantTime maps to effective[x]
  StatementDateTime maps to issued
  DiagnosticReportPerformer maps to performer
  ResultsInterpreter maps to extension
  Specimen maps to specimen
  Observation maps to result (slice on = target.reference.resolve(); slice on type = profile; slice strategy = includes)
  MediaIncluded.CommentOrDescription maps to image.comment
  MediaIncluded.Media maps to image.link
  ConclusionText maps to conclusion
  ConclusionCode maps to codedDiagnosis
  PresentedForm maps to presentedForm

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport obf-DiagnosticReport
... meta
.... extension Slice: Unordered, Open by value:url
.... obf-SourceSystem-extension 0..1uriSourceSystem
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-SourceSystem-extension
... extension Slice: Unordered, Open by value:url
... obf-ResultsInterpreter-extension 0..1Reference(Practitioner | Organization)ResultsInterpreter
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-ResultsInterpreter-extension
... obf-BasedOn-extension 0..*Reference(Basic | ReferralRequest | obf-ProcedureRequest | obf-MedicationRequest | obf-CarePlan)BasedOn
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-BasedOn-extension
... category 1..1
... subject Reference(obf-Patient | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Location)The subject of an observation
... result Reference(obf-Observation)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*obf-DiagnosticReport
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... obf-SourceSystem-extension 0..1uriSourceSystem
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-SourceSystem-extension
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ0..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: (unbound) (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: http://tools.ietf.org/html/bcp47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... obf-ResultsInterpreter-extension 0..1Reference(Practitioner | Organization)ResultsInterpreter
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-ResultsInterpreter-extension
... obf-BasedOn-extension 0..*Reference(Basic | ReferralRequest | obf-ProcedureRequest | obf-MedicationRequest | obf-CarePlan)BasedOn
URL: http://mcodeinitiative.org/us/mcode/StructureDefinition/obf-BasedOn-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierId for external references to this report
... status ?!Σ1..1coderegistered | partial | final | corrected | appended | cancelled | entered-in-error
Binding: DiagnosticReportStatus (required)
... category Σ1..1CodeableConceptService category
Binding: Diagnostic Service Section Codes (example)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred)
... subject Σ1..1Reference(obf-Patient | Group | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Location)The subject of an observation
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Clinically Relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ1..1instantDateTime this version was released
... performer Σ1..1Reference(Practitioner | Organization)Responsible Diagnostic Service
... request 0..*Reference(DiagnosticOrder | ProcedureRequest | ReferralRequest)What was requested
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(obf-Observation)Observations - simple, or complex nested groups
... imagingStudy 0..*Reference(ImagingStudy | ImagingObjectSelection)Reference to full details of imaging associated with the diagnostic report
... image Σ0..*BackboneElementKey images associated with this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis 0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (example)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.meta.securityextensibleAll Security Labels
DiagnosticReport.meta.tagexample
DiagnosticReport.languagerequiredhttp://tools.ietf.org/html/bcp47
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnostic Service Section Codes
DiagnosticReport.codepreferredLOINC Diagnostic Report Codes
DiagnosticReport.codedDiagnosisexampleSNOMED CT Clinical Findings

 

Constraints

IdPathDetailsRequirements