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 Diagnostic Report - Report and Note

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:

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

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..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | 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(US Core Encounter Profile) | 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 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm | S | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status` From the FHIR Standard
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://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 | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings` 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 USCoreDiagnosticReportProfileNoteExchange

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
id |  | 1..1 | id | Logical id of this artifact
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
category |  | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
subject |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | 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(US Core Encounter Profile) | 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 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | 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 | S | 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` 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` From the FHIR Standard
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://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 | 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` 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 USCoreDiagnosticReportProfileNoteExchange

Summary

Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 5 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..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | 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(US Core Encounter Profile) | 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 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm | S | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status` From the FHIR Standard
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://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 | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings` 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 USCoreDiagnosticReportProfileNoteExchange

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
id |  | 1..1 | id | Logical id of this artifact
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
category |  | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
subject |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (required)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | 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(US Core Encounter Profile) | 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 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | 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 | S | 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` 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` From the FHIR Standard
DiagnosticReport.category | required | USCoreDiagnosticReportCategory `http://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 | 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` 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 USCoreDiagnosticReportProfileNoteExchange

Summary

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