CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v1.0.0) 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-monthly-diagnosticreport-note | Version: 1.0.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalMonthlyNoteDiagnosticReport | ||
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 Digital Quality Measure. This profile is based on the HL7 FHIR® US Core Diagnostic Report - Report and Note Exchange.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
  id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
  basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
  reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| status |
?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
 Slices for category |
SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: USCoreDiagnosticReportCategory (6.1.0) (required) |
  category:us-core |
SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) |
 code |
SΣ | 1..1 | CodeableConcept | (USCDI) US Core Report Code Binding: USCoreNonLaboratoryCodes (6.1.0) (extensible): LOINC codes |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | (USCDI) Health care event when test ordered |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 effective[x] |
SΣC | 0..1 | (USCDI) Diagnostically relevant time (typically the time of the procedure) | |
| effectiveDateTime |
dateTime S | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) S | US Core PractitionerRole Profile(6.1.0) | US Core CareTeam Profile(6.1.0)) | (USCDI) Responsible Diagnostic Service |
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile(6.1.0) S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations |
| media |
SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link |
SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
| presentedForm |
S | 0..* | Attachment | (USCDI) Entire report as issued |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | |
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes|6.1.0 | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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 USCoreDiagnosticReportProfileNoteExchange
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 id |
1..1 | id | 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 |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| category |
1..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | |
| Slices for category |
Content/Rules for all slices | |||
| category:us-core |
0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 | ||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 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 |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 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 |
?!Σ | 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 |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| status |
?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | ||||
| category:us-core |
SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | ||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) US Core Report Code Binding: USCoreNonLaboratoryCodes (6.1.0) (extensible): LOINC codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣC | 0..1 | (USCDI) Diagnostically relevant time (typically the time of the procedure) | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 0..1 | instant | (USCDI) DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) S | US Core PractitionerRole Profile(6.1.0) | US Core CareTeam Profile(6.1.0)) | (USCDI) Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile(6.1.0) S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
SΣ | 0..* | BackboneElement | (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 |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source | ||||
| conclusion |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | ||||
| presentedForm |
S | 0..* | Attachment | (USCDI) Entire report as issued | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.basedOn.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | ||||
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | ||||
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | ||||
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes|6.1.0 | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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 USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 5 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 |
| id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| status |
?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| Slices for category |
SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: USCoreDiagnosticReportCategory (6.1.0) (required) |
| category:us-core |
SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) |
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) US Core Report Code Binding: USCoreNonLaboratoryCodes (6.1.0) (extensible): LOINC codes |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | (USCDI) Health care event when test ordered |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
SΣC | 0..1 | (USCDI) Diagnostically relevant time (typically the time of the procedure) | |
| effectiveDateTime |
dateTime S | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) S | US Core PractitionerRole Profile(6.1.0) | US Core CareTeam Profile(6.1.0)) | (USCDI) Responsible Diagnostic Service |
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile(6.1.0) S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations |
| media |
SΣ | 0..* | BackboneElement | (USCDI) Key images associated with this report |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link |
SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
| presentedForm |
S | 0..* | Attachment | (USCDI) Entire report as issued |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | |
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes|6.1.0 | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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 USCoreDiagnosticReportProfileNoteExchange
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| id |
1..1 | id | 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 |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| category |
1..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | |
| Slices for category |
Content/Rules for all slices | |||
| category:us-core |
0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileNoteExchange(6.1.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 | ||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 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 |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 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 |
?!Σ | 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 |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| status |
?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | (USCDI) Service category Slice: Unordered, Open by pattern:$this Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | ||||
| category:us-core |
SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: USCoreDiagnosticReportCategory (6.1.0) (required) | ||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) US Core Report Code Binding: USCoreNonLaboratoryCodes (6.1.0) (extensible): LOINC codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣC | 0..1 | (USCDI) Diagnostically relevant time (typically the time of the procedure) | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 0..1 | instant | (USCDI) DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) S | US Core PractitionerRole Profile(6.1.0) | US Core CareTeam Profile(6.1.0)) | (USCDI) Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile(6.1.0) S | US Core Observation Clinical Result Profile S | Observation) | (USCDI) Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
SΣ | 0..* | BackboneElement | (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 |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source | ||||
| conclusion |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | ||||
| presentedForm |
S | 0..* | Attachment | (USCDI) Entire report as issued | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.basedOn.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | ||||
| DiagnosticReport.category | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | ||||
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category|6.1.0 | ||||
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes|6.1.0 | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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 USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 5 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
