German Oncological Data Standard (GOLD)
0.1.0 - CI Build
German Oncological Data Standard (GOLD)
0.1.0 - CI Build
German Oncological Data Standard (GOLD) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/radiological-diagnostic-report | Version: 0.1.0 | |||
| Draft as of 2023-12-13 | Computable Name: Radiological_Diagnostic_Report | |||
Copyright/Legal: CC-BY-SA-4.0 |
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Profile for the base definition of all radiological diagnostic reports.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo |
  category | 1..* | CodeableConcept | Service category | |
   Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
  coding:loinc | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
   system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |
| coding:diagnostic-service-sections | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |
 coding:snomed-ct | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |
| code | ||||
 coding | 1..* | Coding | Code defined by a terminology system | |
 subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
| specimen | 0..0 | |||
| result | S | 0..* | Reference(Observation) | Observations |
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
 category | Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
| coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |
| coding:diagnostic-service-sections | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |
| coding:snomed-ct | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
| coding | Σ | 1..* | Coding | Code defined by a terminology system |
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
| result | S | 0..* | Reference(Observation) | Observations |
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | 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 | error | DiagnosticReport | 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 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category | Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
| coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| coding:diagnostic-service-sections | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| coding:snomed-ct | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
 effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| result | S | 0..* | Reference(Observation) | Observations | ||||
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | ||||
| media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatus | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | 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 | error | DiagnosticReport | 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 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 3 elements
Prohibited: 1 element
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo |
| category | 1..* | CodeableConcept | Service category | |
| Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
| coding:loinc | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |
| coding:diagnostic-service-sections | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |
| coding:snomed-ct | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |
| code | ||||
| coding | 1..* | Coding | Code defined by a terminology system | |
| subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
| specimen | 0..0 | |||
| result | S | 0..* | Reference(Observation) | Observations |
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
| category | Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
| coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |
| coding:diagnostic-service-sections | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |
| coding:snomed-ct | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
| coding | Σ | 1..* | Coding | Code defined by a terminology system |
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
| result | S | 0..* | Reference(Observation) | Observations |
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | 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 | error | DiagnosticReport | 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 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| supportingInfo | S | 0..* | Reference(Observation | Procedure) | Supporting Info URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/supportingInfo | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category | Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
| coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18748-4 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic imaging study | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| coding:diagnostic-service-sections | Σ | 0..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: RAD | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Radiology | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| coding:snomed-ct | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 4201000179104 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Imaging report | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| result | S | 0..* | Reference(Observation) | Observations | ||||
| imagingStudy | S | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | ||||
| media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatus | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | 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 | error | DiagnosticReport | 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 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 3 elements
Prohibited: 1 element
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron