MII_PR_Bildgebung_Radiologischer_Befund (DiagnosticReport) | I | | DiagnosticReport | There are no (further) constraints on this element Element idShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate names Report, Test, Result, Results, Labs, Laboratory Definition The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
Comments This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
Data type DiagnosticReport Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() - dom-6: A resource should have narrative for robust management
text.`div`.exists() - dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
Mappings- rim: Entity. Role, or Act
- workflow: Event
- v2: ORU -> OBR
- rim: Observation[classCode=OBS, moodCode=EVN]
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id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idShort description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Data type string |
meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idShort description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Data type Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Comments 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.
Data type id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed.
Comments 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.
Data type instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.source Short description Identifies where the resource comes from Definition A 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.
Comments 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.
Data type uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profile Short description Profiles this resource claims to conform to Definition Comments 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.
Data type canonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Comments 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.
Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System.
All Security Labels (extensible)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tag Short description Tags applied to this resource Definition Tags 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.
Comments 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.
Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
CommonTags (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Data type uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.language Short description Language of the resource content Definition The base language in which the resource is written.
Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Data type code Binding CommonLanguages (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
text | | 0..1 | Narrative | There are no (further) constraints on this element Element idShort description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Data type Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- rim: N/A
- rim: Act.text?
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contained | | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Data type Resource Mappings- rim: Entity. Role, or Act
- rim: N/A
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extension | I | 0..* | Extension | Element idDiagnosticReport.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
supportingInfo | S I | 0..* | Extension | Element idDiagnosticReport.extension:supportingInfo Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Extension URL http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
id | | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
type | S I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:type Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
reference | S I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:reference Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
id | | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:reference.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:reference.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
url | | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:reference.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL.
Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Data type uri Fixed value Mappings |
value[x] | | 0..1 | | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.extension:reference.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
valueReference | | | Reference(MII_PR_Bildgebung_Radiologischer_Befund | MII_PR_Bildgebung_Radiologische_Befundungsprozedur) | Data type Reference(MII_PR_Bildgebung_Radiologischer_Befund | MII_PR_Bildgebung_Radiologische_Befundungsprozedur) |
url | | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL.
Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Data type uri Fixed value http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo Mappings |
value[x] | | 0..1 | | There are no (further) constraints on this element Element idDiagnosticReport.extension:supportingInfo.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
valueBase64Binary | | | base64Binary | There are no (further) constraints on this element Data type base64Binary |
valueBoolean | | | boolean | There are no (further) constraints on this element Data type boolean |
valueCanonical | | | canonical() | There are no (further) constraints on this element Data type canonical() |
valueCode | | | code | There are no (further) constraints on this element Data type code |
valueDate | | | date | There are no (further) constraints on this element Data type date |
valueDateTime | | | dateTime | There are no (further) constraints on this element Data type dateTime |
valueDecimal | | | decimal | There are no (further) constraints on this element Data type decimal |
valueId | | | id | There are no (further) constraints on this element Data type id |
valueInstant | | | instant | There are no (further) constraints on this element Data type instant |
valueInteger | | | integer | There are no (further) constraints on this element Data type integer |
valueMarkdown | | | markdown | There are no (further) constraints on this element Data type markdown |
valueOid | | | oid | There are no (further) constraints on this element Data type oid |
valuePositiveInt | | | positiveInt | There are no (further) constraints on this element Data type positiveInt |
valueString | | | string | There are no (further) constraints on this element Data type string |
valueTime | | | time | There are no (further) constraints on this element Data type time |
valueUnsignedInt | | | unsignedInt | There are no (further) constraints on this element Data type unsignedInt |
valueUri | | | uri | There are no (further) constraints on this element Data type uri |
valueUrl | | | url | There are no (further) constraints on this element Data type url |
valueUuid | | | uuid | There are no (further) constraints on this element Data type uuid |
valueAddress | | | Address | There are no (further) constraints on this element Data type Address |
valueAge | | | Age | There are no (further) constraints on this element Data type Age |
valueAnnotation | | | Annotation | There are no (further) constraints on this element Data type Annotation |
valueAttachment | | | Attachment | There are no (further) constraints on this element Data type Attachment |
valueCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data type CodeableConcept |
valueCoding | | | Coding | There are no (further) constraints on this element Data type Coding |
valueContactPoint | | | ContactPoint | There are no (further) constraints on this element Data type ContactPoint |
valueCount | | | Count | There are no (further) constraints on this element Data type Count |
valueDistance | | | Distance | There are no (further) constraints on this element Data type Distance |
valueDuration | | | Duration | There are no (further) constraints on this element Data type Duration |
valueHumanName | | | HumanName | There are no (further) constraints on this element Data type HumanName |
valueIdentifier | | | Identifier | There are no (further) constraints on this element Data type Identifier |
valueMoney | | | Money | There are no (further) constraints on this element Data type Money |
valuePeriod | | | Period | There are no (further) constraints on this element Data type Period |
valueQuantity | | | Quantity | There are no (further) constraints on this element Data type Quantity |
valueRange | | | Range | There are no (further) constraints on this element Data type Range |
valueRatio | | | Ratio | There are no (further) constraints on this element Data type Ratio |
valueSampledData | | | SampledData | There are no (further) constraints on this element Data type SampledData |
valueSignature | | | Signature | There are no (further) constraints on this element Data type Signature |
valueTiming | | | Timing | There are no (further) constraints on this element Data type Timing |
valueContactDetail | | | ContactDetail | There are no (further) constraints on this element Data type ContactDetail |
valueContributor | | | Contributor | There are no (further) constraints on this element Data type Contributor |
valueDataRequirement | | | DataRequirement | There are no (further) constraints on this element Data type DataRequirement |
valueExpression | | | Expression | There are no (further) constraints on this element Data type Expression |
valueParameterDefinition | | | ParameterDefinition | There are no (further) constraints on this element Data type ParameterDefinition |
valueRelatedArtifact | | | RelatedArtifact | There are no (further) constraints on this element Data type RelatedArtifact |
valueTriggerDefinition | | | TriggerDefinition | There are no (further) constraints on this element Data type TriggerDefinition |
valueUsageContext | | | UsageContext | There are no (further) constraints on this element Data type UsageContext |
valueDosage | | | Dosage | There are no (further) constraints on this element Data type Dosage |
valueMeta | | | Meta | There are no (further) constraints on this element Data type Meta |
valueReference | | | Reference() | There are no (further) constraints on this element Data type Reference() |
modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.identifier Short description Business identifier for report Alternate names ReportID, Filler ID, Placer ID Definition Identifiers assigned to this report by the performer or other systems.
Requirements Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
Comments Usually assigned by the Information System of the diagnostic service provider (filler id).
Data type Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- workflow: Event.identifier
- w5: FiveWs.identifier
- v2: OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
- rim: id
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basedOn | S I | 0..* | Reference(MII_PR_Bildgebung_Anforderung_Bildgebung | CarePlan) | Element idShort description What was requested Alternate names Request Definition Details concerning a service requested.
Requirements This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Comments Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
Data type Reference(MII_PR_Bildgebung_Anforderung_Bildgebung | CarePlan) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.basedOn
- v2: ORC? OBR-2/3?
- rim: outboundRelationship[typeCode=FLFS].target
|
status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idShort description registered | partial | preliminary | final + Definition The status of the diagnostic report.
Requirements Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Comments Note that FHIR strings SHALL NOT exceed 1MB in size
Data type code Binding The status of the diagnostic report.
DiagnosticReportStatus (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- workflow: Event.status
- w5: FiveWs.status
- v2: OBR-25 (not 1:1 mapping)
- rim: statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
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category | S Σ | 1..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.category Short description Service category Alternate names Department, Sub-department, Service, Discipline Definition A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Comments Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
Data type CodeableConcept Binding Codes for diagnostic service sections.
DiagnosticServiceSectionCodes (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5: FiveWs.class
- v2: OBR-24
- rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
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id | | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.category.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.category.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
coding | S Σ | 1..* | Coding | Element idDiagnosticReport.category.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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loinc | Σ | 0..1 | CodingPattern | Element idDiagnosticReport.category.coding:loinc Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern {
"system": "http://loinc.org",
"code": "18748-4",
"display": "Diagnostic imaging study"
} Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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diagnostic-service-sections | Σ | 0..1 | CodingPattern | Element idDiagnosticReport.category.coding:diagnostic-service-sections Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern {
"system": "http://terminology.hl7.org/CodeSystem/v2-0074",
"code": "RAD"
} Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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snomed-ct | Σ | 1..1 | CodingPattern | Element idDiagnosticReport.category.coding:snomed-ct Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern {
"system": "http://snomed.info/sct",
"code": "4201000179104",
"display": "Imaging report"
} Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.category.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Comments Very often the text is the same as a displayName of one of the codings.
Data type string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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code | S Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idShort description Name/Code for this diagnostic report Alternate names Type Definition A code or name that describes this diagnostic report.
Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Data type CodeableConcept Binding Codes that describe Diagnostic Reports.
LOINCDiagnosticReportCodes (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.code
- w5: FiveWs.what[x]
- v2: OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
- rim: code
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subject | S Σ I | 0..1 | Reference(Patient) | Element idShort description The subject of the report - usually, but not always, the patient Alternate names Patient Definition The 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.
Requirements SHALL know the subject context.
Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data type Reference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.subject
- w5: FiveWs.subject[x]
- v2: PID-3 (no HL7 v2 mapping for Group or Device)
- rim: participation[typeCode=SBJ]
- w5: FiveWs.subject
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encounter | S Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounter Short description Health care event when test ordered Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
Requirements Links the request to the Encounter context.
Comments This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Data type Reference(Encounter) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.encounter
- w5: FiveWs.context
- v2: PV1-19
- rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
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effective[x] | S Σ | 0..1 | | Element idDiagnosticReport.effective[x] Short description Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence Definition The 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.
Requirements Need to know where in the patient history to file/present this report.
Comments If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Sliced: Unordered, Open, by $this(Type) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- v2: OBR-7
- rim: effectiveTime
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effectiveDateTime | S Σ | 0..1 | dateTime | Element idDiagnosticReport.effective[x]:effectiveDateTime Short description Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence Definition The 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.
Requirements Need to know where in the patient history to file/present this report.
Comments If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Data type dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- v2: OBR-7
- rim: effectiveTime
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effectivePeriod | S Σ | 0..1 | Period | Element idDiagnosticReport.effective[x]:effectivePeriod Short description Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence Definition The 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.
Requirements Need to know where in the patient history to file/present this report.
Comments If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Data type Period Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- v2: OBR-7
- rim: effectiveTime
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issued | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idShort description DateTime this version was made Alternate names Date published, Date Issued, Date Verified Definition The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.
Requirements Clinicians need to be able to check the date that the report was released.
Comments May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
Data type instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- w5: FiveWs.recorded
- v2: OBR-22
- rim: participation[typeCode=VRF or AUT].time
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performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performer Short description Responsible Diagnostic Service Alternate names Laboratory, Service, Practitioner, Department, Company, Authorized by, Director Definition The diagnostic service that is responsible for issuing the report.
Requirements Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Comments This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
Data type Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.performer.actor
- w5: FiveWs.actor
- v2: PRT-8 (where this PRT-4-Participation = "PO")
- rim: .participation[typeCode=PRF]
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resultsInterpreter | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreter Short description Primary result interpreter Alternate names Analyzed by, Reported by Definition The practitioner or organization that is responsible for the report's conclusions and interpretations.
Requirements Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Comments Might not be the same entity that takes responsibility for the clinical report.
Data type Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.performer.actor
- w5: FiveWs.actor
- v2: OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
- rim: .participation[typeCode=PRF]
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specimen | I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimen Short description Specimens this report is based on Definition Details about the specimens on which this diagnostic report is based.
Requirements Need to be able to report information about the collected specimens on which the report is based.
Comments If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Data type Reference(Specimen) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: SPM
- rim: participation[typeCode=SBJ]
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result | S I | 0..* | Reference(MII_PR_Bildgebung_Radiologische_Beobachtung) | Element idShort description Observations Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Comments Observations can contain observations.
Data type Reference(MII_PR_Bildgebung_Radiologische_Beobachtung) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: OBXs
- rim: outboundRelationship[typeCode=COMP].target
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imagingStudy | S I | 1..* | Reference(MII_PR_Bildgebung_Bildgebungsstudie) | Element idDiagnosticReport.imagingStudy Short description Reference to full details of imaging associated with the diagnostic report Definition One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
Comments ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Data type Reference(MII_PR_Bildgebung_Bildgebungsstudie) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
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media | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description Key images associated with this report Alternate names DICOM, Slides, Scans Definition A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Requirements Many diagnostic services include images in the report as part of their service.
Data type BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: OBX?
- rim: outboundRelationship[typeCode=COMP].target
|
id | | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
link | Σ I | 1..1 | Reference(Media) | There are no (further) constraints on this element Element idDiagnosticReport.media.link Short description Reference to the image source Definition Reference to the image source.
Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data type Reference(Media) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .value.reference
|
conclusion | S | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusion Short description Clinical conclusion (interpretation) of test results Alternate names Report Definition Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
Requirements Need to be able to provide a conclusion that is not lost among the basic result data.
Comments Note that FHIR strings SHALL NOT exceed 1MB in size
Data type string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: OBX
- rim: inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
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conclusionCode | S | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCode Short description Codes for the clinical conclusion of test results Definition One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.
Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Data type CodeableConcept Binding Diagnosis codes provided as adjuncts to the report.
SNOMEDCTClinicalFindings (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: OBX
- rim: inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
|
id | | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCode.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data type string Mappings |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCode.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
coding | S Σ | 0..* | Coding | Element idDiagnosticReport.conclusionCode.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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icd10-gm | S Σ | 0..* | CodingPattern | Element idDiagnosticReport.conclusionCode.coding:icd10-gm Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern {
"system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm"
} Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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sct | S Σ | 0..* | CodingPattern | Element idDiagnosticReport.conclusionCode.coding:sct Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Requirements Allows for alternative encodings within a code system, and translations to other code systems.
Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Data type Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern {
"system": "http://snomed.info/sct"
} Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCode.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Comments Very often the text is the same as a displayName of one of the codings.
Data type string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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presentedForm | S I | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedForm Short description Entire report as issued Definition Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Requirements Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.
Comments "application/pdf" is recommended as the most reliable and interoperable in this context.
Data type Attachment Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - att-1: If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()
Mappings- rim: n/a
- v2: ED/RP
- rim: ED
- v2: OBX
- rim: text (type=ED)
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