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
Resource Profile: ACH Monthly Event Diagnostic Report - Report and Note
| Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-monthly-diagnosticreport-note | Version: 3.0.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: AcuteCareHospitalMonthlyNoteDiagnosticReport | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.1002.42.16 | ||||
This profile contains Required and Must Support data elements for reporting diagnostic report- report and note information to the NHSN Acute Care Hospital (ACH) Monthly dQM. This profile inherits from the QI-Core 6.0.0 DiagnosticReport Profile for Report and Note Exchange profile, which inherits from the US Core 6.1.0 DiagnosticReport Profile for Report and Note Exchange profile.
Usages:
- Refer to this Profile: ACH Monthly Event Procedure
- Examples for this Profile: DiagnosticReport/diagnosticreport-example-ach-monthly-pass2-radiology
You can also check for usages in the FHIR IG Statistics
Changes since version 1.0.0:
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type |
Description & Constraints Filter: 
|
|---|---|---|---|---|
  DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportNote(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
  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 |
|
  basedOn
|
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|
  reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
status
|
C | 1..1 | code |
(NHSN-MS) (USCDI) registered | partial | preliminary | final +Binding: DiagnosticReportStatus (required) |
 Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service Category
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): 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:us-core
|
0..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service CategoryBinding: USCoreDiagnosticReportCategory (6.1.0) (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
|
 code
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) QI-Core Report CodeBinding: USCoreNonLaboratoryCodes (6.1.0) (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(QICore Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Health care event when test ordered |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
 effective[x]
|
C | 1..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) |
|
|
effectiveDateTime
|
dateTime | |||
|
effectivePeriod
|
Period | |||
|
issued
|
0..1 | instant |
(NHSN-MS) (QI-Core)(USCDI) DateTime this version was made |
|
|
performer
|
0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|
|
result
|
0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
|
|
media
|
0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report |
|
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|
|
link
|
1..1 | Reference(Media) | (USCDI) Reference to the image source | |
|
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 | (USCDI) Entire report as issued |
|
|
Documentation for this format
| ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:us-core | Base | required | US Core Diagnostic Report Category Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.code | Base | extensible | US Core Non Laboratory Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
Constraints
| 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-10 | 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()
|
This structure is derived from QICoreDiagnosticReportNote
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
0..* | QICoreDiagnosticReportNote(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 |
|
|
basedOn
|
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
status
|
1..1 | code | (NHSN-MS)(USCDI) registered | partial | preliminary | final + | |
|
category
|
1..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service Category | |
|
Slices for category
|
Content/Rules for all slices | |||
|
category:us-core
|
0..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service Category | |
|
code
|
1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) QI-Core Report 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(QICore Encounter) {b} | (NHSN-MS)(QI-Core)(USCDI) Health care event when test ordered | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
effective[x]
|
1..1 | dateTime, Period | (NHSN-MS)(QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
|
issued
|
0..1 | instant | (NHSN-MS)(QI-Core)(USCDI) DateTime this version was made | |
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test results |
|
|
Documentation for this format
| ||||
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportNote(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
||||
|
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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|||||
|
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 | |||||
|
status
|
C | 1..1 | code |
(NHSN-MS) (USCDI) registered | partial | preliminary | final +Binding: DiagnosticReportStatus (required) |
||||
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service Category
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): 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:us-core
|
0..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service CategoryBinding: USCoreDiagnosticReportCategory (6.1.0) (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
|||||
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) QI-Core Report CodeBinding: USCoreNonLaboratoryCodes (6.1.0) (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(QICore Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) 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 | 1..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) |
|||||
|
effectiveDateTime
|
dateTime | |||||||
|
effectivePeriod
|
Period | |||||||
|
issued
|
0..1 | instant |
(NHSN-MS) (QI-Core)(USCDI) DateTime this version was made |
|||||
|
performer
|
0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|||||
|
resultsInterpreter
|
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
|||||
|
specimen
|
0..* | Reference(Specimen) | Specimens this report is based on |
|||||
|
result
|
0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
|||||
|
imagingStudy
|
0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report |
|||||
|
media
|
0..* | BackboneElement | (QI-Core)(USCDI) 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) | (USCDI) Reference to the image source | |||||
|
conclusion
|
0..1 | string | 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 | (USCDI) Entire report as issued |
|||||
|
Documentation for this format
| ||||||||
Terminology Bindings
| 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.basedOn.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:us-core | Base | required | US Core Diagnostic Report Category Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.code | Base | extensible | US Core Non Laboratory 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.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
Constraints
| 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-10 | 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()
|
This structure is derived from QICoreDiagnosticReportNote
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
- Cross-Measure Patient Profile (http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/cross-measure-patient)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)
Extensions
This structure refers to these extensions:
Maturity: 2
Key Elements View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportNote(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
|
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 |
|
|
basedOn
|
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
status
|
C | 1..1 | code |
(NHSN-MS) (USCDI) registered | partial | preliminary | final +Binding: DiagnosticReportStatus (required) |
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service Category
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): 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:us-core
|
0..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service CategoryBinding: USCoreDiagnosticReportCategory (6.1.0) (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
|
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) QI-Core Report CodeBinding: USCoreNonLaboratoryCodes (6.1.0) (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(QICore Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Health care event when test ordered |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
effective[x]
|
C | 1..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) |
|
|
effectiveDateTime
|
dateTime | |||
|
effectivePeriod
|
Period | |||
|
issued
|
0..1 | instant |
(NHSN-MS) (QI-Core)(USCDI) DateTime this version was made |
|
|
performer
|
0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|
|
result
|
0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
|
|
media
|
0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report |
|
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|
|
link
|
1..1 | Reference(Media) | (USCDI) Reference to the image source | |
|
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 | (USCDI) Entire report as issued |
|
|
Documentation for this format
| ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:us-core | Base | required | US Core Diagnostic Report Category Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.code | Base | extensible | US Core Non Laboratory Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
Constraints
| 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-10 | 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()
|
Differential View
This structure is derived from QICoreDiagnosticReportNote
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
DiagnosticReport
|
0..* | QICoreDiagnosticReportNote(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 |
|
|
basedOn
|
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
status
|
1..1 | code | (NHSN-MS)(USCDI) registered | partial | preliminary | final + | |
|
category
|
1..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service Category | |
|
Slices for category
|
Content/Rules for all slices | |||
|
category:us-core
|
0..* | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Service Category | |
|
code
|
1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) QI-Core Report 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(QICore Encounter) {b} | (NHSN-MS)(QI-Core)(USCDI) Health care event when test ordered | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
effective[x]
|
1..1 | dateTime, Period | (NHSN-MS)(QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
|
issued
|
0..1 | instant | (NHSN-MS)(QI-Core)(USCDI) DateTime this version was made | |
|
conclusionCode
|
0..* | CodeableConcept |
(NHSN-MS) Codes for the clinical conclusion of test results |
|
|
Documentation for this format
| ||||
Snapshot View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
DiagnosticReport
|
C | 0..* | QICoreDiagnosticReportNote(6.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
||||
|
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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) {b} |
(NHSN-MS) What was requested |
|||||
|
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 | |||||
|
status
|
C | 1..1 | code |
(NHSN-MS) (USCDI) registered | partial | preliminary | final +Binding: DiagnosticReportStatus (required) |
||||
|
Slices for category
|
1..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service Category
Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): 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:us-core
|
0..* | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Service CategoryBinding: USCoreDiagnosticReportCategory (6.1.0) (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
|||||
|
code
|
1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) QI-Core Report CodeBinding: USCoreNonLaboratoryCodes (6.1.0) (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(QICore Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) 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 | 1..1 |
(NHSN-MS) (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) |
|||||
|
effectiveDateTime
|
dateTime | |||||||
|
effectivePeriod
|
Period | |||||||
|
issued
|
0..1 | instant |
(NHSN-MS) (QI-Core)(USCDI) DateTime this version was made |
|||||
|
performer
|
0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
|||||
|
resultsInterpreter
|
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
|||||
|
specimen
|
0..* | Reference(Specimen) | Specimens this report is based on |
|||||
|
result
|
0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
|||||
|
imagingStudy
|
0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report |
|||||
|
media
|
0..* | BackboneElement | (QI-Core)(USCDI) 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) | (USCDI) Reference to the image source | |||||
|
conclusion
|
0..1 | string | 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 | (USCDI) Entire report as issued |
|||||
|
Documentation for this format
| ||||||||
Terminology Bindings
| 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.basedOn.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📦4.0.1 | FHIR Std. |
| DiagnosticReport.category:us-core | Base | required | US Core Diagnostic Report Category Codes | 📍6.1.0 | US Core v6.1 |
| DiagnosticReport.code | Base | extensible | US Core Non Laboratory 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.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📦4.0.1 | FHIR Std. |
Constraints
| 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-10 | 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()
|
This structure is derived from QICoreDiagnosticReportNote
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
- Cross-Measure Patient Profile (http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/cross-measure-patient)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
