MII IG Pathologie-Befund EN v2026
Pathology Report (DiagnosticReport)
Description
The MII PR Patho Report profile of the DiagnosticReport resource represents the complete findings report without document properties (see MII-PR-Patho-Composition).
It presents highly structured examination results, including human-readable texts (narratives), that belong to "panels" of individual examinations. It collects and organizes pathology findings for even complex individual results and can reference additional information about the examination panel, e.g., clinical information and sample information. A complete, formatted finding text should be part of the MII PR Patho Report.
The most important features of the MII PR Patho Report are:
- the ability to include additional clinical context, e.g., a mix of results from individual observations, images, text, and formatted representations.
- the ability to organize information on multiple specimens/samples, which is not currently possible in the MII PR Patho Finding profile.
- and the ability to display a summary assessment, the Conclusion, as well as one or more Conclusion codes that are not identical to Pathology Findings.
The MII PR Patho Report, as an entry in the "diagnostic-report" section of the MII PR Patho Composition profile, forms the core of a persistent "Pathology Finding Report" document.
| Name | Canonical |
|---|---|
| MII_PR_Patho_Report | https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report |
| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata 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.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version 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. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies 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. In 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.
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags 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. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A 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. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, 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. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Documentation relevant to the 'parent' resource Alternate namesextensions, user content DefinitionDocumentation or 'knowledge artifacts' relevant to the base resource such as citations, supporting evidence, documentation of processes, caveats around testing methodology. Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions 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). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) Constraints
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| Set-ID | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-IDShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
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| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
General http://www.acme.com/identifiers/patientMappings
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| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| basedOn | S | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionDetails concerning a service requested. This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(MII_PR_Patho_Service_Request) Constraints
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| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.statusShort description registered | partial | preliminary | final + DefinitionThe status of the diagnostic report. Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
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| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Service category Alternate namesDepartment, Sub-department, Service, Discipline DefinitionA code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) Constraints
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| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version 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. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol 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). Need to refer to a particular code in the system.
60568-3Mappings
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If 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). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain 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. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | S Σ | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context.
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| encounter | S Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
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| effective[x] | S Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
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| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
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| performer | S Σ | 1..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Might not be the same entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| specimen | S | 1..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
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| result | S | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Observations Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) Constraints
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| intraoperative-observations | S | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| macroscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| microscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| additional-observations | S | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| diagnostic-conclusion | S | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| imagingStudy | S | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
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| link | S Σ | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. Reference(MII_PR_Patho_Attached_Image) Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
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| conclusionCode | S | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
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| presentedForm | S | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
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| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata 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.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version 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. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies 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. In 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.
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags 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. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A 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. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, 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. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Documentation relevant to the 'parent' resource Alternate namesextensions, user content DefinitionDocumentation or 'knowledge artifacts' relevant to the base resource such as citations, supporting evidence, documentation of processes, caveats around testing methodology. Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions 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). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) Constraints
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| Set-ID | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-IDShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
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| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
General http://www.acme.com/identifiers/patientMappings
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| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| basedOn | S | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionDetails concerning a service requested. This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(MII_PR_Patho_Service_Request) Constraints
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| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.statusShort description registered | partial | preliminary | final + DefinitionThe status of the diagnostic report. Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
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| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Service category Alternate namesDepartment, Sub-department, Service, Discipline DefinitionA code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) Constraints
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| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version 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. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol 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). Need to refer to a particular code in the system.
60568-3Mappings
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If 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). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain 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. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | S Σ | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context.
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| encounter | S Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
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| effective[x] | S Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
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| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
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| performer | S Σ | 1..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Might not be the same entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| specimen | S | 1..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
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| result | S | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Observations Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) Constraints
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| intraoperative-observations | S | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| macroscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| microscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| additional-observations | S | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| diagnostic-conclusion | S | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| imagingStudy | S | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
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| link | S Σ | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. Reference(MII_PR_Patho_Attached_Image) Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
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| conclusionCode | S | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
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| presentedForm | S | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
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| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata 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.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version 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. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies 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. In 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.
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags 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. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A 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. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, 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. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Documentation relevant to the 'parent' resource Alternate namesextensions, user content DefinitionDocumentation or 'knowledge artifacts' relevant to the base resource such as citations, supporting evidence, documentation of processes, caveats around testing methodology. Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions 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). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) Constraints
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| Set-ID | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-IDShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
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| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
General http://www.acme.com/identifiers/patientMappings
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| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| basedOn | S | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionDetails concerning a service requested. This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(MII_PR_Patho_Service_Request) Constraints
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| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.statusShort description registered | partial | preliminary | final + DefinitionThe status of the diagnostic report. Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
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| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Service category Alternate namesDepartment, Sub-department, Service, Discipline DefinitionA code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) Constraints
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| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version 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. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol 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). Need to refer to a particular code in the system.
60568-3Mappings
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If 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). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain 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. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | S Σ | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context.
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| encounter | S Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
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| effective[x] | S Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
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| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
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| performer | S Σ | 1..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Might not be the same entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
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| specimen | S | 1..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
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| result | S | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Observations Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) Constraints
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| intraoperative-observations | S | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| macroscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| microscopic-observations | S | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| additional-observations | S | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| diagnostic-conclusion | S | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| imagingStudy | S | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
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| link | S Σ | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. Reference(MII_PR_Patho_Attached_Image) Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
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| conclusionCode | S | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
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| presentedForm | S | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
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In the table below, elements marked with * are duplicated in the MII PR Patho Composition profile.
List of all must-support data elements
| FHIR element | Explanation |
|---|---|
| DiagnosticReport.id | Must-support, but optional |
| DiagnosticReport.meta | Must-support, but optional |
| DiagnosticReport.text | Not recommended optional narrative, compiled from the texts of the grouper observations and/or the observations (see Composition.text and Composition.section.text) |
| DiagnosticReport.extension:related-report | Reference to previous finding(s) that are factually related to the current finding |
| DiagnosticReport.identifier | Finding number (incoming number, case number, filler order number, accession number) |
| *DiagnosticReport.basedOn | Reference to the initial ServiceRequest, must always be given |
| DiagnosticReport.status | No specifications, preliminary findings are permitted |
| DiagnosticReport.category | Extensible binding to ValueSet MII VS Patho Report Category HL7 |
| DiagnosticReport.code | LOINC 60568-3 “Pathology Synoptic Report” |
| *DiagnosticReport.subject | Patient (inherited from the Person module of the MII https://www.medizininformatik-initiative.de/fhir/core/modul-person/StructureDefinition/Patient) |
| DiagnosticReport.encounter | Must support, but optional |
| *DiagnosticReport.effective[x] | Time of sample collection (time at which the measured property in the sample material (e.g., analyte concentration) presumably corresponded to the property in the patient). If not documented, the laboratory receipt time is the closest time point. Must be identical to Observation.effective[x].extension: Clinical reference time point. This information is stored in both the DiagnosticReport and the Observation to facilitate subsequent data evaluation. |
| *DiagnosticReport.issued | Time of release of the finding |
| *DiagnosticReport.performer | Reference to the institution (custodian) responsible for the report. |
| DiagnosticReport.specimen | References to all samples (parts), sent by the clinician to the pathology laboratory. Future specifications for additional core dataset modules may define requirements in this regard. |
| DiagnosticReport.result | The DiagnosticReport should contain at least one result in the form of a Grouper Observation DiagnosticConclusion (22637-3 (Pathology report diagnosis)). |
| DiagnosticReport.imagingStudy | Embedded images |
| DiagnosticReport.media | Embedded images |
| DiagnosticReport.conclusion | Textual description of the final medical assessment of the findings |
| DiagnosticReport.conclusionCode | Coded final assessment(s) |
| DiagnosticReport.presentedForm | PDF of the pathology report |
Mapping to Logical Model
| FHIR Element | Logical Data Model |
|---|---|
| DiagnosticReport.id | Befundbericht.id |
| DiagnosticReport.identifier | Befundbericht.Identifikator |
| DiagnosticReport.basedOn | Untersuchungsauftrag |
| DiagnosticReport.status | Befundbericht.Status |
| DiagnosticReport.category | Befundbericht.Kategorie |
| DiagnosticReport.code | Befundbericht.Typ |
| DiagnosticReport.subject | Patient |
| DiagnosticReport.encounter | Referenz zum Modul Fall |
| DiagnosticReport.effective | Befundbericht.Datum |
| DiagnosticReport.issued | Befundbericht.Datum |
| DiagnosticReport.performer | Practitioner/Organization |
| DiagnosticReport.specimen | Probe |
| DiagnosticReport.result | Beobachtungsberichtabschnitt und Generische Pathologisch-anatomische Einzelbeobachtung |
| DiagnosticReport.media | Generische Pathologisch-anatomische Einzelbeobachtung.EingebettetesBild, Generische Pathologisch-anatomische Einzelbeobachtung.ROI |
| DiagnosticReport.conclusion | Befundbericht.Bewertung |
| DiagnosticReport.conclusionCode | Befundbericht.Kodierung |
| DiagnosticReport.presentedForm | Befundbericht.PDF |
Search Parameters
The following search parameters are relevant for the Pathology Report module, also in combination:
The search parameter
_idMUST be supported:Examples:
GET [base]/DiagnosticReport?_id=103270Usage notes: Further information on searching for
_idcan be found in the FHIR base specification - section "Parameters for all resources".The search parameter
_lastUpdatedMUST be supported:Examples:
GET [base]/DiagnosticReport?_lastUpdated=2021-12-08Usage notes: Further information on searching for
_lastUpdatedcan be found in the FHIR base specification - section "Parameters for all resources".The search parameter
_profileMUST be supported:Examples:
GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-reportUsage notes: Further information on searching for
_profilecan be found in the FHIR base specification - section "Parameters for all resources".The search parameter
based-onMUST be supported:Examples:
GET [base]/DiagnosticReport?based-on=ServiceRequest/mii-exa-patho-requestUsage notes: Further information on searching for
DiagnosticReport.basedOncan be found in the FHIR base specification - section "reference".The search parameter
categoryMUST be supported:Examples:
GET [base]/DiagnosticReport?category=CPGET [base]/DiagnosticReport?category=http://terminology.hl7.org/CodeSystem/v2-0074|CPUsage notes: Further information on searching for
DiagnosticReport.categorycan be found in the FHIR base specification - section "token".The search parameter
codeMUST be supported:Examples:
GET [base]/DiagnosticReport?code=http://loinc.org|60568-3GET [base]/DiagnosticReport?code=60568-3Usage notes: Further information on searching for
DiagnosticReport.codecan be found in the FHIR base specification - section "token".The search parameter
conclusionMUST be supported:Examples:
GET [base]/DiagnosticReport?conclusion=http://snomed.info/sct|399490008GET [base]/DiagnosticReport?conclusion=399490008Usage notes: Further information on searching for
DiagnosticReport.conclusionCodecan be found in the FHIR base specification - section "token".The search parameter
dateMUST be supported:Examples:
GET [base]/DiagnosticReport?date=2021-06-01Usage notes: Further information on searching for
DiagnosticReport.effectivecan be found in the FHIR base specification - section "date".The search parameter
encounterMUST be supported:Examples:
GET [base]/DiagnosticReport?encounter=Encounter/234980Usage notes: Further information on searching for
DiagnosticReport.encountercan be found in the FHIR base specification - section "reference".The search parameter
identifierMUST be supported:Examples:
GET [base]/DiagnosticReport?identifier=https://pathologie.klinikum-karlsruhe.de/fhir/fn/befundbericht|E21.12345GET [base]/DiagnosticReport?identifier=E21.12345Usage notes: Further information on searching for
DiagnosticReport.identifiercan be found in the FHIR base specification - section "token".The search parameter
issuedMUST be supported:Examples:
GET [base]/DiagnosticReport?issued=2022-01-01Usage notes: Further information on searching for
DiagnosticReport.issuedcan be found in the FHIR base specification - section "date".The search parameter
mediaMUST be supported:Examples:
GET [base]/DiagnosticReport?media=Media/ex-mii-patho-attached-imageUsage notes: Further information on searching for
DiagnosticReport.media.linkcan be found in the FHIR base specification - section "reference".The search parameter
patientMUST be supported:Examples:
GET [base]/DiagnosticReport?patient=Patient/12345Usage notes: Further information on searching for
DiagnosticReport.subject.where(resolve() is Patient)can be found in the FHIR base specification - section "reference".The search parameter
performerMUST be supported:Examples:
GET [base]/DiagnosticReport?performer=Practitioner/2346545Usage notes: Further information on searching for
DiagnosticReport.performercan be found in the FHIR base specification - section "reference".The search parameter
resultMUST be supported:Examples:
GET [base]/DiagnosticReport?result=Observation/ex-mii-patho-macro-grouper-bUsage notes: Further information on searching for
DiagnosticReport.resultcan be found in the FHIR base specification - section "reference".The search parameter
specimenMUST be supported:Examples:
GET [base]/DiagnosticReport?specimen=Specimen/987976Usage notes: Further information on searching for
DiagnosticReport.specimencan be found in the FHIR base specification - section "reference".The search parameter
statusMUST be supported:Examples:
GET [base]/DiagnosticReport?status=finalUsage notes: Further information on searching for
DiagnosticReport.statuscan be found in the FHIR base specification - section "token".The search parameter
subjectMUST be supported:Examples:
GET [base]/DiagnosticReport?subject=Patient/12345Usage notes: Further information on searching for
DiagnosticReport.subjectcan be found in the FHIR base specification - section "reference".The search parameter
imaging-studyMUST be supported:Examples:
GET [base]/DiagnosticReport?imaging-study=ImagingStudy/978698Usage notes: Further information on searching for
DiagnosticReport.imagingStudycan be found in the FHIR base specification - section "reference".
Examples
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