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 - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: ACH Monthly Event General Diagnostic Report

Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-monthly-diagnosticreport | Version: 1.0.0
Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalMonthlyDiagnosticReport

This profile contains Required and Must Support data elements for reporting general diagnostic report information to the NHSN Acute Care Hospital (ACH) Monthly Digital Quality Measure. This profile is based on the HL7 FHIR® R4 DiagnosticReport Resource v4.0.1.

Usages:

- Examples for this Profile: DiagnosticReport/diagnosticreport-example-ach-monthly-pass2-cardiopulmonary

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category | S Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Health care event when test ordered
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From the FHIR Standard
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings|4.0.1` From the FHIR Standard

#### Constraints

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 DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | 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
status | S | 1..1 | code | registered | partial | preliminary | final +
category | S | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Health care event when test ordered
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report
issued | S | 0..1 | instant | DateTime this version was made
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 | S Σ C | 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 | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category | S Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | 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 | S Σ C | 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 | S Σ | 0..1 | Reference(Encounter) | 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 | S Σ C | 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] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 |  | 0..* | Reference(Observation) | Observations
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | 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 |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
DiagnosticReport.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.basedOn.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From the FHIR Standard
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.encounter.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings|4.0.1` From the FHIR Standard

#### Constraints

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 DiagnosticReport

Summary

Mandatory: 5 elements(2 nested mandatory elements)
Must-Support: 12 elements

Extensions

This structure refers to these extensions:

- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category | S Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Health care event when test ordered
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From the FHIR Standard
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings|4.0.1` From the FHIR Standard

#### Constraints

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 DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | 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
status | S | 1..1 | code | registered | partial | preliminary | final +
category | S | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Health care event when test ordered
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report
issued | S | 0..1 | instant | DateTime this version was made
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 | S Σ C | 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 | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category | S Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (extensible)
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (extensible)
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | 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 | S Σ C | 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 | S Σ | 0..1 | Reference(Encounter) | 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 | S Σ C | 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] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 |  | 0..* | Reference(Observation) | Observations
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | 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 |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
DiagnosticReport.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.basedOn.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From the FHIR Standard
DiagnosticReport.category | extensible | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | extensible | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.encounter.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings|4.0.1` From the FHIR Standard

#### Constraints

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 DiagnosticReport

Summary

Mandatory: 5 elements(2 nested mandatory elements)
Must-Support: 12 elements

Extensions

This structure refers to these extensions:

- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension

Maturity: 1

Other representations of profile: CSV, Excel, Schematron