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-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 Digital Quality Measure. 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:
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..* | 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
| ||||
| 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. |
| 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
| ||||||||
| 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. |
| 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:
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
| ||||
| 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. |
| 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
| ||||||||
| 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. |
| 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:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
