CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
This page is part of the CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG (v1.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, 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: ![]()
|
|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
|
![]() ![]() |
Σ | 1..1 | id | Logical id of this artifact |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
![]() ![]() |
SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required) |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
![]() ![]() |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
SΣ | 1..1 | Time of the report or note | |
![]() ![]() ![]() |
dateTime | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() |
SΣ | 0..1 | instant | DateTime this version was made |
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
![]() ![]() |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
![]() ![]() |
S | 0..* | Attachment | Entire report as issued |
Documentation for this format
| ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required |
DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status
From the FHIR Standard
|
|
| DiagnosticReport.category | required |
USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
|
|
| DiagnosticReport.code | extensible |
USCoreDiagnosticreportReportAndNoteCodes(a valid code from LOINC)http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
|
|
| DiagnosticReport.conclusionCode | example |
SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings
From 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() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
| Name | Flags | Card. | Type |
Description & Constraints Filter: ![]()
|
|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
![]() ![]() |
1..1 | id | Logical id of this artifact | |
![]() ![]() |
||||
![]() ![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() ![]() |
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
1..* | CodeableConcept |
Service category Binding: US Core DiagnosticReport Category (required) |
|
![]() ![]() |
||||
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
||||
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
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
|
| Name | Flags | Card. | Type |
Description & Constraints Filter: ![]()
|
||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
|||||
![]() ![]() |
Σ | 1..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
Σ | 0..1 | instant | When the resource version last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
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Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
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![]() ![]() ![]() |
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". |
||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
|
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![]() ![]() |
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 |
|||||
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0..* | Resource | Contained, inline Resources |
|||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations |
|||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier for report |
||||
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
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). |
||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
||||
![]() ![]() |
SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required) |
||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
||||
![]() ![]() |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
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). |
||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
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). |
||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
SΣ | 1..1 | Time of the report or note | |||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
SΣ | 0..1 | instant | DateTime this version was made | ||||
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
||||
![]() ![]() |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
||||
![]() ![]() |
0..* | Reference(Specimen) | Specimens this report is based on |
|||||
![]() ![]() |
0..* | Reference(Observation) | Observations |
|||||
![]() ![]() |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
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![]() ![]() |
Σ | 0..* | BackboneElement | Key images associated with this report |
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![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations |
|||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
||||
![]() ![]() ![]() |
0..1 | string | Comment about the image (e.g. explanation) | |||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
![]() ![]() |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
![]() ![]() |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
||||
![]() ![]() |
S | 0..* | Attachment | 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|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.meta.tag | example |
CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.language | preferred |
CommonLanguageshttp://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
|
||||
| DiagnosticReport.basedOn.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.status | required |
DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status
From the FHIR Standard
|
||||
| DiagnosticReport.category | required |
USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
|
||||
| DiagnosticReport.code | extensible |
USCoreDiagnosticreportReportAndNoteCodes(a valid code from LOINC)http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
|
||||
| DiagnosticReport.subject.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.encounter.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.conclusionCode | example |
SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings
From 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() |
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: ![]()
|
|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
|
![]() ![]() |
Σ | 1..1 | id | Logical id of this artifact |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
![]() ![]() |
SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required) |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
![]() ![]() |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered |
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
SΣ | 1..1 | Time of the report or note | |
![]() ![]() ![]() |
dateTime | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() |
SΣ | 0..1 | instant | DateTime this version was made |
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
![]() ![]() |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
![]() ![]() |
S | 0..* | Attachment | Entire report as issued |
Documentation for this format
| ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required |
DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status
From the FHIR Standard
|
|
| DiagnosticReport.category | required |
USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
|
|
| DiagnosticReport.code | extensible |
USCoreDiagnosticreportReportAndNoteCodes(a valid code from LOINC)http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
|
|
| DiagnosticReport.conclusionCode | example |
SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings
From 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() |
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
| Name | Flags | Card. | Type |
Description & Constraints Filter: ![]()
|
|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
![]() ![]() |
1..1 | id | Logical id of this artifact | |
![]() ![]() |
||||
![]() ![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() ![]() |
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
1..* | CodeableConcept |
Service category Binding: US Core DiagnosticReport Category (required) |
|
![]() ![]() |
||||
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
||||
![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
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
|
Snapshot View
| Name | Flags | Card. | Type |
Description & Constraints Filter: ![]()
|
||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
|||||
![]() ![]() |
Σ | 1..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
Σ | 0..1 | instant | When the resource version last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
||||
![]() ![]() ![]() |
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". |
||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
|
|||||
![]() ![]() |
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 |
|||||
![]() ![]() |
0..* | Resource | Contained, inline Resources |
|||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations |
|||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier for report |
||||
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
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). |
||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
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SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required) |
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SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
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SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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). |
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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). |
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣ | 1..1 | Time of the report or note | |||||
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dateTime | |||||||
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Period | |||||||
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SΣ | 0..1 | instant | DateTime this version was made | ||||
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SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
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0..* | Reference(Specimen) | Specimens this report is based on |
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0..* | Reference(Observation) | Observations |
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0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
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Σ | 0..* | BackboneElement | Key images associated with this report |
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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0..1 | string | Comment about the image (e.g. explanation) | |||||
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Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
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0..1 | string | Clinical conclusion (interpretation) of test results | |||||
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S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
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S | 0..* | Attachment | Entire report as issued |
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Documentation for this format
| ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.meta.security | extensible |
All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1
From the FHIR Standard
|
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| DiagnosticReport.meta.tag | example |
CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.language | preferred |
CommonLanguageshttp://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
|
||||
| DiagnosticReport.basedOn.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.status | required |
DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status
From the FHIR Standard
|
||||
| DiagnosticReport.category | required |
USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
|
||||
| DiagnosticReport.code | extensible |
USCoreDiagnosticreportReportAndNoteCodes(a valid code from LOINC)http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
|
||||
| DiagnosticReport.subject.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.encounter.type | extensible |
ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
|
||||
| DiagnosticReport.conclusionCode | example |
SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings
From 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() |
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