CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
3.0.0 - Release 3 - draft
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
3.0.0 - Release 3 - draft
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v3.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-daily-diagnosticreport-lab | Version: 3.0.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: AcuteCareHospitalDailyEventLabDiagnosticReport | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.1002.42.1 | ||||
This profile contains Required and Must Support data elements for reporting diagnostic report lab information for the NHSN Acute Care Hospital (ACH) Daily Digital Quality Measure. This profile inherits from the QI Core 6.0.0 DiagnosticReport Profile for Laboratory Results Reporting profile, which inherits from the US Core 6.1.0 DiagnosticReport Profile for Laboratory Results Reporting profile.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 1.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type |
Description & Constraints Filter: 
|
|---|---|---|---|---|
  DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-8, us-core-9 |
  id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |
 modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|
|
status
|
C | 1..1 | code |
(NHSN-MS) final | registered | preliminary | partialBinding: ACH Daily Diagnostic Report Status ValueSet (required) |
  Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Classification of diagnostic report
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
   category:LaboratorySlice
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service categoryBinding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Required Pattern: At least the following |
|
  id
|
0..1 | string | Unique id for inter-element referencing | |
 extension
|
0..* | Extension | Additional content defined by implementations | |
|
text
|
0..1 | string | Plain text representation of the concept | |
 coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology systemFixed Value: (Complex) |
|
|
id
|
0..1 | string | Unique id for inter-element referencing | |
|
extension
|
0..* | Extension | Additional content defined by implementations | |
 system
|
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
|
|
version
|
0..1 | string | Version of the system - if relevant | |
|
code
|
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
|
|
display
|
0..1 | string | Representation defined by the system | |
 userSelected
|
0..1 | boolean | If this coding was chosen directly by the user | |
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (USCDI) US Core Laboratory Report Order CodeBinding: US Core Laboratory Test Codes (extensible): LOINC codes |
|
 subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
 effective[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) |
|
|
effectiveDateTime
|
dateTime | |||
|
effectivePeriod
|
Period | |||
|
issued
|
C | 0..1 | instant |
(NHSN-MS) (QI-Core) (USCDI) When the report was released |
|
performer
|
0..* | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} |
(NHSN-MS) (QI-Core)(USCDI) Observations |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test resultsBinding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
| DiagnosticReport.category | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:LaboratorySlice | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | extensible | US Core Laboratory Test Codes | 📦6.1.0 | US Core v6.1 |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
|
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists()
|
This structure is derived from QICoreDiagnosticReportLab
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
meta
|
||||
 Slices for extension
|
Content/Rules for all slices | |||
 extension:link-received-date-extension
|
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
|
status
|
1..1 | code | (NHSN-MS) final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) |
|
|
category
|
1..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Classification of diagnostic report | |
|
Slices for category
|
Content/Rules for all slices | |||
|
category:LaboratorySlice
|
1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service category | |
 coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology system |
|
|
code
|
1..1 | CodeableConcept | (NHSN-MS)(USCDI) US Core Laboratory Report Order Code | |
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} | (NHSN-MS)(QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
effective[x]
|
0..1 | dateTime, Period | (NHSN-MS)(QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) | |
|
issued
|
0..1 | instant | (NHSN-MS)(QI-Core) (USCDI) When the report was released | |
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} | (NHSN-MS)(QI-Core)(USCDI) Observations | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test results |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-8, us-core-9 |
||||
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|||||
|
meta
|
0..1 | Meta | Metadata about the resource | |||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
 Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:link-received-date-extension
|
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
|
versionId
|
0..1 | id | Version specific identifier | |||||
|
lastUpdated
|
0..1 | instant | When the resource version last changed | |||||
|
source
|
0..1 | uri | Identifies where the resource comes from | |||||
|
profile
|
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
|||||
|
security
|
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
|||||
|
tag
|
0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
|||||
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |||||
|
language
|
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
|
|||||
|
text
|
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
|||||
|
contained
|
0..* | Resource | Contained, inline Resources |
|||||
|
extension
|
0..* | Extension | Additional content defined by implementations |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|||||
|
identifier
|
0..* | Identifier | Business identifier for report |
|||||
|
basedOn
|
0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested |
|||||
|
status
|
C | 1..1 | code |
(NHSN-MS) final | registered | preliminary | partialBinding: ACH Daily Diagnostic Report Status ValueSet (required) |
||||
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Classification of diagnostic report
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|||||
|
category:LaboratorySlice
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service categoryBinding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Required Pattern: At least the following |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
 coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology systemFixed Value: (Complex) |
|||||
 id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations | |||||
|
system
|
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
|||||
|
version
|
0..1 | string | Version of the system - if relevant | |||||
|
code
|
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
|||||
|
display
|
0..1 | string | Representation defined by the system | |||||
|
userSelected
|
0..1 | boolean | If this coding was chosen directly by the user | |||||
|
text
|
0..1 | string | Plain text representation of the concept | |||||
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (USCDI) US Core Laboratory Report Order CodeBinding: US Core Laboratory Test Codes (extensible): LOINC codes |
|||||
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
effective[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) |
|||||
|
effectiveDateTime
|
dateTime | |||||||
|
effectivePeriod
|
Period | |||||||
|
issued
|
C | 0..1 | instant |
(NHSN-MS) (QI-Core) (USCDI) When the report was released |
||||
|
performer
|
0..* | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|||||
|
resultsInterpreter
|
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
|||||
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} |
(NHSN-MS) (QI-Core)(USCDI) Observations |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
imagingStudy
|
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
|||||
|
media
|
0..* | BackboneElement | Key images associated with this report |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|||||
|
comment
|
0..1 | string | Comment about the image (e.g. explanation) | |||||
|
link
|
1..1 | Reference(Media) | Reference to the image source | |||||
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|||||
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test resultsBinding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
|||||
|
presentedForm
|
0..* | Attachment | Entire report as issued |
|||||
|
Documentation for this format
| ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
| DiagnosticReport.category | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:LaboratorySlice | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | extensible | US Core Laboratory Test Codes | 📦6.1.0 | US Core v6.1 |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.encounter.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.specimen.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.result.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
|
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists()
|
This structure is derived from QICoreDiagnosticReportLab
Summary
Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Key Elements View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-8, us-core-9 |
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|
|
status
|
C | 1..1 | code |
(NHSN-MS) final | registered | preliminary | partialBinding: ACH Daily Diagnostic Report Status ValueSet (required) |
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Classification of diagnostic report
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
|
category:LaboratorySlice
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service categoryBinding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Required Pattern: At least the following |
|
|
id
|
0..1 | string | Unique id for inter-element referencing | |
|
extension
|
0..* | Extension | Additional content defined by implementations | |
|
text
|
0..1 | string | Plain text representation of the concept | |
|
coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology systemFixed Value: (Complex) |
|
|
id
|
0..1 | string | Unique id for inter-element referencing | |
|
extension
|
0..* | Extension | Additional content defined by implementations | |
|
system
|
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
|
|
version
|
0..1 | string | Version of the system - if relevant | |
|
code
|
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
|
|
display
|
0..1 | string | Representation defined by the system | |
|
userSelected
|
0..1 | boolean | If this coding was chosen directly by the user | |
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (USCDI) US Core Laboratory Report Order CodeBinding: US Core Laboratory Test Codes (extensible): LOINC codes |
|
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
effective[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) |
|
|
effectiveDateTime
|
dateTime | |||
|
effectivePeriod
|
Period | |||
|
issued
|
C | 0..1 | instant |
(NHSN-MS) (QI-Core) (USCDI) When the report was released |
|
performer
|
0..* | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} |
(NHSN-MS) (QI-Core)(USCDI) Observations |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test resultsBinding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
| DiagnosticReport.category | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:LaboratorySlice | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | extensible | US Core Laboratory Test Codes | 📦6.1.0 | US Core v6.1 |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
|
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists()
|
Differential View
This structure is derived from QICoreDiagnosticReportLab
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
meta
|
||||
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:link-received-date-extension
|
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
|
status
|
1..1 | code | (NHSN-MS) final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) |
|
|
category
|
1..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Classification of diagnostic report | |
|
Slices for category
|
Content/Rules for all slices | |||
|
category:LaboratorySlice
|
1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service category | |
|
coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology system |
|
|
code
|
1..1 | CodeableConcept | (NHSN-MS)(USCDI) US Core Laboratory Report Order Code | |
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} | (NHSN-MS)(QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
effective[x]
|
0..1 | dateTime, Period | (NHSN-MS)(QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) | |
|
issued
|
0..1 | instant | (NHSN-MS)(QI-Core) (USCDI) When the report was released | |
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} | (NHSN-MS)(QI-Core)(USCDI) Observations | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test results |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
Snapshot View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportLab(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-8, us-core-9 |
||||
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|||||
|
meta
|
0..1 | Meta | Metadata about the resource | |||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:link-received-date-extension
|
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
|
versionId
|
0..1 | id | Version specific identifier | |||||
|
lastUpdated
|
0..1 | instant | When the resource version last changed | |||||
|
source
|
0..1 | uri | Identifies where the resource comes from | |||||
|
profile
|
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
|||||
|
security
|
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
|||||
|
tag
|
0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
|||||
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |||||
|
language
|
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
|
|||||
|
text
|
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
|||||
|
contained
|
0..* | Resource | Contained, inline Resources |
|||||
|
extension
|
0..* | Extension | Additional content defined by implementations |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|||||
|
identifier
|
0..* | Identifier | Business identifier for report |
|||||
|
basedOn
|
0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested |
|||||
|
status
|
C | 1..1 | code |
(NHSN-MS) final | registered | preliminary | partialBinding: ACH Daily Diagnostic Report Status ValueSet (required) |
||||
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Classification of diagnostic report
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|||||
|
category:LaboratorySlice
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service categoryBinding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections. Required Pattern: At least the following |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
coding
|
1..* | Coding |
(NHSN-MS) Code defined by a terminology systemFixed Value: (Complex) |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations | |||||
|
system
|
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
|||||
|
version
|
0..1 | string | Version of the system - if relevant | |||||
|
code
|
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
|||||
|
display
|
0..1 | string | Representation defined by the system | |||||
|
userSelected
|
0..1 | boolean | If this coding was chosen directly by the user | |||||
|
text
|
0..1 | string | Plain text representation of the concept | |||||
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (USCDI) US Core Laboratory Report Order CodeBinding: US Core Laboratory Test Codes (extensible): LOINC codes |
|||||
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) Health care event when test ordered |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
effective[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of specimen collection) |
|||||
|
effectiveDateTime
|
dateTime | |||||||
|
effectivePeriod
|
Period | |||||||
|
issued
|
C | 0..1 | instant |
(NHSN-MS) (QI-Core) (USCDI) When the report was released |
||||
|
performer
|
0..* | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|||||
|
resultsInterpreter
|
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
|||||
|
specimen
|
0..* | Reference(ACH Daily Event Specimen) {b} |
(NHSN-MS) Specimens this report is based on |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
result
|
0..* | Reference(QICore Laboratory Result Observation) {b} |
(NHSN-MS) (QI-Core)(USCDI) Observations |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
imagingStudy
|
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
|||||
|
media
|
0..* | BackboneElement | Key images associated with this report |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|||||
|
comment
|
0..1 | string | Comment about the image (e.g. explanation) | |||||
|
link
|
1..1 | Reference(Media) | Reference to the image source | |||||
|
conclusion
|
0..1 | string |
(NHSN-MS) Clinical conclusion (interpretation) of test results |
|||||
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test resultsBinding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
|||||
|
presentedForm
|
0..* | Attachment | Entire report as issued |
|||||
|
Documentation for this format
| ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | ACH Daily Diagnostic Report Status ValueSet | 📦3.0.0 | This IG |
| DiagnosticReport.category | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:LaboratorySlice | Base | preferred | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | extensible | US Core Laboratory Test Codes | 📦6.1.0 | US Core v6.1 |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.encounter.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.specimen.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.result.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
|
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
(status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists()
|
This structure is derived from QICoreDiagnosticReportLab
Summary
Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
