| MII_PR_Bildgebung_Anforderung_Bildgebung (ServiceRequest) | C | | ServiceRequest | There are no (further) constraints on this element Element idServiceRequest Short descriptionA request for a service to be performed Alternate namesdiagnostic request, referral, referral request, transfer of care request DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed.
Data typeServiceRequest Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.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-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-6: A resource should have narrative for robust management
text.`div`.exists() - dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty() - prr-1: orderDetail SHALL only be present if code is present
orderDetail.empty() or code.exists() Mappings- rim: Entity. Role, or Act
- workflow: Request
- v2: ORC
- rim: Act[moodCode<=INT]
|
| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.id Short descriptionLogical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
CommentsThe only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Data typestring |
| meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idServiceRequest.meta Short descriptionMetadata about the resource DefinitionThe 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.
Data typeMeta ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.meta.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.meta.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idServiceRequest.meta.versionId Short descriptionVersion specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
CommentsThe server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
Data typeid ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idServiceRequest.meta.lastUpdated Short descriptionWhen the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed.
CommentsThis 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. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Data typeinstant ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element idServiceRequest.meta.source Short descriptionIdentifies where the resource comes from DefinitionA uri that identifies the source system of the resource. 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.
CommentsIn the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idServiceRequest.meta.profile Short descriptionProfiles this resource claims to conform to DefinitionCommentsIt 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.
Data typecanonical(StructureDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idServiceRequest.meta.security Short descriptionSecurity Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
CommentsThe 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.
Data typeCoding BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
|
| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idServiceRequest.meta.tag Short descriptionTags applied to this resource DefinitionTags 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.
CommentsThe 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.
Data typeCoding BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
CommonTags (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
|
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idServiceRequest.implicitRules Short descriptionA set of rules under which this content was created DefinitionA 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.
CommentsAsserting 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.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idServiceRequest.language Short descriptionLanguage of the resource content DefinitionThe base language in which the resource is written.
CommentsLanguage 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).
Data typecode BindingCommonLanguages (preferred) Binding extensionsConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
| text | | 0..1 | Narrative | There are no (further) constraints on this element Element idServiceRequest.text Short descriptionText summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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.
CommentsContained 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.
Data typeNarrative ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- rim: N/A
- rim: Act.text?
|
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idServiceRequest.contained Short descriptionContained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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.
CommentsThis 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.
Data typeResource Mappings- rim: Entity. Role, or Act
- rim: N/A
|
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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).
RequirementsModifier 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idServiceRequest.identifier Short descriptionIdentifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller.
CommentsThe identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
Data typeIdentifier ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- workflow: Request.identifier
- w5: FiveWs.identifier
- v2: ORC.2, ORC.3, RF1-6 / RF1-11,
- rim: .identifier
- quick: ClinicalStatement.identifier
|
| instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element idServiceRequest.instantiatesCanonical Short descriptionInstantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest.
CommentsNote: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
Data typecanonical(ActivityDefinition | PlanDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.instantiatesCanonical
- v2: Varies by domain
- rim: .outboundRelationship[typeCode=DEFN].target
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| instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element idServiceRequest.instantiatesUri Short descriptionInstantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest.
CommentsThis might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.instantiatesUri
- v2: Varies by domain
- rim: .outboundRelationship[typeCode=DEFN].target
|
| basedOn | Σ C | 0..* | Reference(CarePlan | MedicationRequest | ServiceRequest) | There are no (further) constraints on this element Element idServiceRequest.basedOn Short descriptionWhat request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request.
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(CarePlan | MedicationRequest | ServiceRequest) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.basedOn
- v2: ORC.8 (plus others)
- rim: .outboundRelationship[typeCode=FLFS].target
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| replaces | Σ C | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element idServiceRequest.replaces Short descriptionWhat request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s).
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(ServiceRequest) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.replaces
- v2: Handled by message location of ORC (ORC.1=RO or RU)
- rim: .outboundRelationship[typeCode=RPLC].target
|
| requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idServiceRequest.requisition Short descriptionComposite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier.
RequirementsSome business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes.
CommentsRequests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
Data typeIdentifier ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- workflow: Request.groupIdentifier
- v2: ORC.4
- rim: .inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier
|
| status | S Σ ?! | 1..1 | codeBinding | Element idServiceRequest.status Short descriptionStatus DefinitionEntwurf | Aktiv | Wartend | Widerrufen | Abgeschlossen | Fehlerhafte Eingabe | Unbekannt
CommentsThe status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource.
Data typecode BindingThe status of a service order.
RequestStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.status
- w5: FiveWs.status
- v2: ORC.5,RF1-1
- rim: .status
- quick: Action.currentStatus
|
| intent | S Σ ?! | 1..1 | codeBinding | Element idServiceRequest.intent Short descriptionAbsicht DefinitionVorschlag | Plan | Anweisung | Erstverordnung | Reflexverordnung | Füllverordnung | Beispielverordnung | Option
CommentsThis element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Data typecode BindingThe kind of service request.
RequestIntent (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.intent
- w5: FiveWs.class
- v2: N/A
- rim: .moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)
|
| category | S Σ | 1..* | CodeableConcept | Element idServiceRequest.category Short descriptionKategorie DefinitionKategorie der Serviceanforderung
RequirementsUsed for filtering what service request are retrieved and displayed.
CommentsThere may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.
Data typeCodeableConcept BindingClassification of the requested service.
ServiceRequestCategoryCodes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5: FiveWs.class
- v2: RF1-5
- rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="INT"].code
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.category.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.category.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| coding | S Σ | 1..* | Coding | Element idServiceRequest.category.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding SlicingUnordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| (All Slices) | | | | The requirements in this element apply to all slices |
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.category.coding.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.category.coding.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idServiceRequest.category.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
RequirementsNeed to be unambiguous about the source of the definition of the symbol.
CommentsThe 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.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.category.coding.version Short descriptionVersion of the system - if relevant DefinitionThe 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.
CommentsWhere 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.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idServiceRequest.category.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA 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).
RequirementsNeed to refer to a particular code in the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typecode ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.category.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
RequirementsNeed to be able to carry a human-readable meaning of the code for readers that do not know the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idServiceRequest.category.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
RequirementsThis 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.
CommentsAmongst 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.
Data typeboolean ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| sct | S Σ | 0..1 | CodingPattern | Element idServiceRequest.category.coding:sct Short descriptionSNOMED CT Code DefinitionEin Verweis auf einen von SNOMED CT definierten Code
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Pattern{
"system": "http://snomed.info/sct",
"code": "363679005",
"display": "Imaging (procedure)"
}Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.category.text Short descriptionPlain text representation of the concept DefinitionA 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.
RequirementsThe 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.
CommentsVery often the text is the same as a displayName of one of the codings.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idServiceRequest.priority Short descriptionroutine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Meaning when missingIf missing, this task should be performed with normal priority
Data typecode BindingIdentifies the level of importance to be assigned to actioning the request.
RequestPriority (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.priority
- w5: FiveWs.grade
- v2: TQ1.9, RF1-2
- rim: .priorityCode
|
| doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idServiceRequest.doNotPerform Short descriptionTrue if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed.
RequirementsUsed for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.
CommentsIn general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
Meaning when missingIf missing, the request is a positive request e.g. "do perform"
Data typeboolean ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.doNotPerform
- rim: .actionNegationInd
|
| code | S Σ | 1..1 | CodeableConcept | Element idServiceRequest.code Short descriptionKode Alternate namesservice requested DefinitionKode der Serviceanforderung in LOINC, RadLex oder SNOMED CT
CommentsMany laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code.
Data typeCodeableConcept BindingCodes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available here.
ProcedureCodes(SNOMEDCT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Request.code
- w5: FiveWs.what[x]
- v2: PR1-3 / OBR-4 (varies by domain)
- rim: .code
- quick: Procedure.procedureCode
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.code.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.code.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| coding | S Σ | 1..* | Coding | Element idServiceRequest.code.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding SlicingUnordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| (All Slices) | | | | The requirements in this element apply to all slices |
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.code.coding.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.code.coding.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idServiceRequest.code.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
RequirementsNeed to be unambiguous about the source of the definition of the symbol.
CommentsThe 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.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.code.coding.version Short descriptionVersion of the system - if relevant DefinitionThe 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.
CommentsWhere 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.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idServiceRequest.code.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA 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).
RequirementsNeed to refer to a particular code in the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typecode ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.code.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
RequirementsNeed to be able to carry a human-readable meaning of the code for readers that do not know the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idServiceRequest.code.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
RequirementsThis 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.
CommentsAmongst 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.
Data typeboolean ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| loinc | S Σ | 0..1 | CodingBindingPattern | Element idServiceRequest.code.coding:loinc Short descriptionLOINC Code DefinitionEin Verweis auf einen vom LOINC definierten Code
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding Bindinghttp://loinc.org/vs/loinc-rsna-radiology-playbook (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Pattern{
"system": "http://loinc.org"
}Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| sct | S Σ | 0..1 | CodingBindingPattern | Element idServiceRequest.code.coding:sct Short descriptionSNOMED CT Code DefinitionEin Verweis auf einen von SNOMED CT definierten Code
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding BindingProcedureCodes(SNOMEDCT) (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Pattern{
"system": "http://snomed.info/sct"
}Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.code.text Short descriptionPlain text representation of the concept DefinitionA 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.
RequirementsThe 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.
CommentsVery often the text is the same as a displayName of one of the codings.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| orderDetail | Σ C | 0..* | CodeableConcept | There are no (further) constraints on this element Element idServiceRequest.orderDetail Short descriptionAdditional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. 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.
CommentsFor information from the medical record intended to support the delivery of the requested services, use the supportingInformation element.
Data typeCodeableConcept BindingCodified order entry details which are based on order context.
ServiceRequestOrderDetailsCodes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, prr-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: NTE
- rim: .code
- quick: Procedure.procedureCode
|
| quantity[x] | Σ | 0..1 | | There are no (further) constraints on this element Element idServiceRequest.quantity[x] Short descriptionService amount DefinitionAn 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).
RequirementsWhen ordering a service the number of service items may need to be specified separately from the the service item.
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: NTE
- rim: .quantity
|
| quantityQuantity | | | Quantity | There are no (further) constraints on this element Data typeQuantity |
| quantityRange | | | Range | There are no (further) constraints on this element Data typeRange |
| quantityRatio | | | Ratio | There are no (further) constraints on this element Data typeRatio |
| subject | S Σ C | 1..1 | Reference(Patient) | Element idServiceRequest.subject Short descriptionPerson DefinitionPerson, auf die sich die Anforderung bezieht
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(Patient) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.subject
- w5: FiveWs.subject[x]
- v2: PID
- rim: .participation[typeCode=SBJ].role
- quick: ClinicalStatement.subject
- w5: FiveWs.subject
|
| encounter | S Σ C | 0..1 | Reference(Encounter) | Element idServiceRequest.encounter Short descriptionVersorgungsstellenkontakt Alternate namescontext DefinitionReferenz auf den Versorgungsstellenkontakt
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(Encounter) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.encounter
- w5: FiveWs.context
- v2: PV1
- rim: .inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN]
- quick: ClinicalStatement.encounter
|
| occurrence[x] | Σ | 0..1 | | There are no (further) constraints on this element Element idServiceRequest.occurrence[x] Short descriptionWhen service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.occurrence[x]
- w5: FiveWs.planned
- v2: TQ1/TQ2, OBR-7/OBR-8
- rim: .effectiveTime
- quick: Procedure.procedureSchedule
|
| occurrenceDateTime | | | dateTime | There are no (further) constraints on this element Data typedateTime |
| occurrencePeriod | | | Period | There are no (further) constraints on this element Data typePeriod |
| occurrenceTiming | | | Timing | There are no (further) constraints on this element Data typeTiming |
| asNeeded[x] | Σ | 0..1 | | There are no (further) constraints on this element Element idServiceRequest.asNeeded[x] Short descriptionPreconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc.
BindingA coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc.
SNOMEDCTMedicationAsNeededReasonCodes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- rim: boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code="Assertion"].value
- quick: Proposal.prnReason.reason
|
| asNeededBoolean | | | boolean | There are no (further) constraints on this element Data typeboolean |
| asNeededCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data typeCodeableConcept |
| authoredOn | S Σ | 0..1 | dateTime | Element idServiceRequest.authoredOn Short descriptionErstellungszeitpunkt Alternate namesorderedOn DefinitionErstellungszeitpunkt der Anforderung
Data typedateTime ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- workflow: Request.authoredOn
- w5: FiveWs.recorded
- v2: ORC.9, RF1-7 / RF1-9
- rim: .participation[typeCode=AUT].time
- quick: Proposal.proposedAtTime
|
| requester | S Σ C | 0..1 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Element idServiceRequest.requester Short descriptionAnforderer Alternate namesauthor, orderer DefinitionPerson, die die Anforderung erstellt
CommentsThis not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource.
Data typeReference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.requester
- w5: FiveWs.author
- v2: ORC.12, PRT
- rim: .participation[typeCode=AUT].role
- quick: ClinicalStatement.statementAuthor
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| performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idServiceRequest.performerType Short descriptionPerformer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service.
CommentsThis is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”.
Data typeCodeableConcept BindingIndicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc.
ParticipantRoles (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Request.performerType
- w5: FiveWs.actor
- v2: PRT, RF!-3
- rim: .participation[typeCode=PRF].role[scoper.determinerCode=KIND].code
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| performer | Σ C | 0..* | Reference(CareTeam | Device | HealthcareService | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idServiceRequest.performer Short descriptionRequested performer Alternate namesrequest recipient DefinitionThe desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc.
CommentsIf multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B).
Data typeReference(CareTeam | Device | HealthcareService | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.performer
- w5: FiveWs.actor
- v2: PRT, Practitioner: PRD-2/PRD-7 where PRD-3 = RT; Organization: PRD-10 where PRD-3 = RT
- rim: .participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]
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| locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idServiceRequest.locationCode Short descriptionRequested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center.
CommentsNot all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Data typeCodeableConcept BindingA location type where services are delivered.
v3.ServiceDeliveryLocationRoleType (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5: FiveWs.actor
- rim: .participation[typeCode=LOC].role[scoper.determinerCode=KIND].code
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| locationReference | Σ C | 0..* | Reference(Location) | There are no (further) constraints on this element Element idServiceRequest.locationReference Short descriptionRequested location DefinitionA reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center.
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(Location) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.actor
- rim: .participation[typeCode=LOC].role[scoper.determinerCode=INSTANCE]
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| reasonCode | S Σ | 0..* | CodeableConcept | Element idServiceRequest.reasonCode Short descriptionAnforderungsgrund Definitionkodierter Grund für die Anforderung
CommentsThis element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use CodeableConcept.text element if the data is free (uncoded) text as shown in the CT Scan example.
Data typeCodeableConcept BindingDiagnosis or problem codes justifying the reason for requesting the service investigation.
ProcedureReasonCodes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Request.reasonCode
- w5: FiveWs.why[x]
- v2: ORC.16, RF1-10
- rim: .reasonCode
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| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.reasonCode.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.reasonCode.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| coding | S Σ | 1..* | Coding | Element idServiceRequest.reasonCode.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding SlicingUnordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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| (All Slices) | | | | The requirements in this element apply to all slices |
| id | | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
CommentsThere 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.
Data typeExtension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
RequirementsNeed to be unambiguous about the source of the definition of the symbol.
CommentsThe 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.
Data typeuri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.version Short descriptionVersion of the system - if relevant DefinitionThe 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.
CommentsWhere 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.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
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| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA 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).
RequirementsNeed to refer to a particular code in the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typecode ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
RequirementsNeed to be able to carry a human-readable meaning of the code for readers that do not know the system.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idServiceRequest.reasonCode.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
RequirementsThis 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.
CommentsAmongst 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.
Data typeboolean ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
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| sct | S Σ | 0..1 | CodingBindingPattern | Element idServiceRequest.reasonCode.coding:sct Short descriptionSNOMED CT Code DefinitionEin Verweis auf einen von SNOMED CT definierten Code
RequirementsAllows for alternative encodings within a code system, and translations to other code systems.
CommentsCodes 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.
Data typeCoding BindingMII_VS_Bildgebung_Findings_SCT (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Pattern{
"system": "http://snomed.info/sct"
}Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.reasonCode.text Short descriptionPlain text representation of the concept DefinitionA 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.
RequirementsThe 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.
CommentsVery often the text is the same as a displayName of one of the codings.
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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| reasonReference | S Σ C | 0..* | Reference(Condition | DiagnosticReport | DocumentReference | Observation) | Element idServiceRequest.reasonReference Short descriptionAnforderungbezug DefinitionGrund, auf den sich die Anforderung bezieht
CommentsThis element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in DiagnosticReport.conclusion and/or DiagnosticReport.conclusionCode. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in ServiceRequest.reasonCode if the data is free (uncoded) text as shown in the CT Scan example.
Data typeReference(Condition | DiagnosticReport | DocumentReference | Observation) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.reasonReference
- w5: FiveWs.why[x]
- v2: ORC.16
- rim: .outboundRelationship[typeCode=RSON].target
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| insurance | C | 0..* | Reference(ClaimResponse | Coverage) | There are no (further) constraints on this element Element idServiceRequest.insurance Short descriptionAssociated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service.
CommentsReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data typeReference(ClaimResponse | Coverage) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.insurance
- v2: IN1/IN2
- rim: .outboundRelationship[typeCode=COVBY].target
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| supportingInfo | S C | 0..* | Reference(DiagnosticReport | ImagingStudy) | Element idServiceRequest.supportingInfo Short descriptionZusatzinformation Alternate namesAsk at order entry question, AOE DefinitionZusätzliche Informationen zur Anforderung
CommentsTo represent information about how the services are to be delivered use the instructions element.
Data typeReference(DiagnosticReport | ImagingStudy) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.supportingInfo
- v2: Accompanying segments
- rim: .outboundRelationship[typeCode=PERT].target
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| specimen | Σ C | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idServiceRequest.specimen Short descriptionProcedure Samples DefinitionOne or more specimens that the laboratory procedure will use.
CommentsMany diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
Data typeReference(Specimen) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: SPM
- rim: .participation[typeCode=SPC].role
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idServiceRequest.bodySite Short descriptionLocation on Body Alternate nameslocation DefinitionAnatomic location where the procedure should be performed. This is the target site.
RequirementsKnowing where the procedure is performed is important for tracking if multiple sites are possible.
CommentsOnly used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure.
Data typeCodeableConcept BindingCodes describing anatomical locations. May include laterality.
SNOMEDCTBodyStructures (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: SPM
- rim: targetSiteCode
- quick: Procedure.targetBodySite
|
| note | | 0..* | Annotation | There are no (further) constraints on this element Element idServiceRequest.note Short descriptionComments DefinitionAny other notes and comments made about the service request. For example, internal billing notes.
CommentsFor systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
Data typeAnnotation ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: N/A
- rim: Act
- workflow: Request.note
- v2: NTE
- rim: .inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST]
- quick: ClinicalStatement.additionalText
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| patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element idServiceRequest.patientInstruction Short descriptionPatient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer.
CommentsNote that FHIR strings SHALL NOT exceed 1MB in size
Data typestring ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- rim: n/a
- v2: NTE
- rim: .text
|
| relevantHistory | C | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element idServiceRequest.relevantHistory Short descriptionRequest provenance DefinitionKey events in the history of the request.
CommentsThis might not include provenances for all versions of the request – only those deemed “relevant” or important.
This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude
All Provenances should have some historical version of this Request as their subject.
Data typeReference(Provenance) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Request.relevantHistory
- v2: N/A
- rim: .inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]
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