Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the STU3 profiles here.
Official URL: https://fhir.interweavedigital.nhs.uk/R4/StructureDefinition/Interweave-DiagnosticReport | Version: 0.0.1 | |||
Draft as of 2024-07-15 | Computable Name: InterweaveDiagnosticReport |
Interweave DiagnosticReport resource profile - DRAFT.
Status: DRAFT: For Review
This profile sets out the expectations for the interweave DiagnosticReport resource. We use the UKCore-DiagnosticReport structure definition as a base to this profile.
As noted in the FHIR specifications, a Diagnostic Report allows for presenting a combination of:
The following mandatory fields are defined:
Status - The status of the diagnostic report. This is mandatory in FHIR, with a short list of codes provided. Most commonly the status will be "final". (Other statuses may be used if relevant, but must be kept up-to-date)
Subject - every Diagnostic Report must be linked to a Patient.
Issued date - when the report was issued.
Category - A code that classifies the clinical discipline, department or diagnostic service that created the report. Provides a high-level categorisation of the report. This is based on a short and simple list provided by FHIR which is expected to be straightforward to map to (eg "Radiology"). Useful for sorting and filtering.
Code - A code or name that describes this diagnostic report. This is mandatory in FHIR and defines in more detail the type of diagnostic report. The coding of diagnostic reports is known to be a difficult topic, and at this stage a single set of codes is difficult to prescribe. However the following are preferred, most favoured first:
SNOMED - UKCore defines the use of SNOMED coding based on the use of 371525003 - Clinical procedure report
NICIP - this code list covers only imaging. However within that domain it has been defined by NHS Digital and mandated for use by the Information Standards Board. See https://digital.nhs.uk/services/terminology-and-classifications/national-interim-clinical-imaging-procedure-nicip-code-set. Note that the NICIP codes include a maintained standard mapping to SNOMED, and so typically the associated SNOMED code can also be provided as a second coding
LOINC - the default mapping in FHIR is to LOINC codes for diagnostic reporting
Local Codes - outside of the imaging domain there is significant variation in coding and, whilst mapping to one of the above standards is preferred, it may not always be feasible.
NB: Any intention to use local codes must be explicitly discussed and approved
NB: In all cases display text must be provided so that, regardless of coding, the type of report can be understood by a user
In addition the following fields are "Must Support" – i.e., they must be populated if relevant and known.
identifier - A Local Id should be provided, such that could be quoted if manually getting in touch to find out more.
encounter - This provides a link to the Encounter. Whilst there will not always be an Encounter, it is important to populate if it is relevant - to help build the complete picture by linking together all activities surrounding the Encounter.
Effective[x] - Clinically relevant time/time-period for report. This is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
Result - this allows for (semi) structured results to be offered in the form of a list of Observations. Whilst some types of Diagnostic Report are purely textual, for others these structured Observations are extremely important.
Note: The relevant Observations for different types of report, and tips for populating from common Radiology and Lab systems is potentially a topic for a further paper in its own right
Presented Form - this allows for a textual report to be offered. This must be provided whenever a written report "document" is present.
Within "presented form" it is mandatory to populate the Content Type, so that consumers can be aware and process accordingly.
Data Providers and Data Consumers SHOULD support the following contentTypes:
- application/pdf
- text/html
- image/jpeg
- image/png (currently not supported in Interweave Portal, however it is on the roadmap)
(This list may be added to by request and discussion)
Other contentTypes should only be used with caution, as not all Data Consumers may be able to view them.
Other fields are optional and may be populated if known – on the understanding that not all data consumers will necessarily make use of them. Points of note include:
extension:noteR5 - Comments about the diagnostic report. This is a R5 backport. It may include general statements about the diagnostic report, or statements about significant, unexpected or unreliable results values contained within the diagnostic report, or information about its source when relevant to its interpretation.
extension:supportingInfoR5 - Additional info supporting the diagnostic report. This is a R5 backport. This backbone element contains supporting information that was used in the creation of the report not included in the results already included in the report.
basedOn - What was requested. Details concerning a service requested.
Performer - again this may be useful if available. (Noting that for a regional shared care record the practitioner managing the overall encounter may often be of greater relevance).
Specimen - if relevant and available then details of the specimen should be provided.
Conclusion - this is an important field, and only considered "optional" due to the potential difficulty of populating it in practice. It provides a brief summary of the findings, typically easier to understand than the technical detail of the full report. This information can often be found in the "comments" field(s) of a lab or RIS system. However the wide variation in usage of these "comments" fields can make it challenging to identify and extract reliably.
conclusionCode - this is in effect the "conclusion" in coded form. Whilst this could obviously be useful to populate, it often may not be feasible given the challenges described above in extracting even a text-based conclusion.
resultsInterpreter - Removed.
media and Imaging Study - The priority for the shared care record is to share results and reports, rather than raw image data. Please note that there is no support for retrieving these imaging links. (Note that this position could change in future - please get in touch if you have a specific use-case).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from UKCoreDiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | UKCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | Content/Rules for all slices | |||
extension:compositionReferenceR5 | 0..0 | |||
Slices for identifier | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | |
identifier:All Slices | Content/Rules for all slices | |||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
identifier:localIdentifier | S | 0..1 | Identifier | Business identifier for report |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-diagnosticReport-identifier |
value | S | 1..1 | string | The Local diagnosticReport Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
basedOn | 0..* | Reference(InterweaveCarePlan | InterweaveMedicationRequest | InterweaveServiceRequest) | What was requested | |
category | 1..1 | CodeableConcept | A code that classifies the clinical discipline, department or diagnostic service that created the report. Binding: DiagnosticServiceSectionCodes (required) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
code | ||||
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:coding.system | |
coding:snomedCT | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
code | S | 1..1 | code | SNOMED CT Clinical Procedure Report code Binding: UK Core Report Code (required) |
display | S | 1..1 | string | Representation defined by the system |
coding:nicip | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/CodeSystem/Interweave-NICIP |
code | S | 1..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIPcodes (required) |
display | S | 1..1 | string | Representation defined by the system |
coding:loinc | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | S | 1..1 | code | LOINC code Binding: LOINCDiagnosticReportCodes (required) |
display | S | 1..1 | string | Representation defined by the system |
subject | 1..1 | Reference(InterweavePatient) | The subject of the report - usually, but not always, the patient. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
encounter | 0..1 | Reference(InterweaveEncounter) | Health care event when test ordered. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
effective[x] | S | 0..1 | dateTime, Period | Clinically relevant time/time-period for report |
issued | 1..1 | instant | Clinically relevant time / time-period for report. | |
resultsInterpreter | 0..0 | |||
result | ||||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
imagingStudy | 0..* | Reference(ImagingStudy) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
media | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
conclusionCode | ||||
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
presentedForm | S | 0..* | Attachment | Entire report as issued |
contentType | S | 1..1 | code | Mime type of the content, with charset etc. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.category | required | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code.coding:snomedCT.code | required | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | |
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIPcodeshttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-NICIP from this IG | |
DiagnosticReport.code.coding:loinc.code | required | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | UKCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | Content/Rules for all slices | |||||||
noteR5 | 0..* | (Complex) | Comments about the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note" | |||||
value[x] | 1..1 | Annotation | Comments about the diagnostic report. | |||||
supportingInfoR5 | 0..* | (Complex) | Additional info supporting the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-diagnosticReport-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnosticReport Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
basedOn | 0..* | Reference(InterweaveCarePlan | InterweaveMedicationRequest | InterweaveServiceRequest) | What was requested | |||||
status | ?!SΣ | 1..1 | code | The status of the diagnostic report. Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | SΣ | 1..1 | CodeableConcept | A code that classifies the clinical discipline, department or diagnostic service that created the report. Binding: DiagnosticServiceSectionCodes (required) | ||||
code | SΣ | 1..1 | CodeableConcept | A code or name that describes this diagnostic report. Binding: UK Core Report Code (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:coding.system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | SΣ | 1..1 | code | SNOMED CT Clinical Procedure Report code Binding: UK Core Report Code (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/CodeSystem/Interweave-NICIP | ||||
code | SΣ | 1..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIPcodes (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
code | SΣ | 1..1 | code | LOINC code Binding: LOINCDiagnosticReportCodes (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | The subject of the report - usually, but not always, the patient. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | Health care event when test ordered. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for report | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 1..1 | instant | Clinically relevant time / time-period for report. | ||||
result | S | 0..* | Reference(Observation) | Observations that are part of this diagnostic report. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |||||
media | Σ | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
contentType | SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.category | required | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | ||||
DiagnosticReport.code.coding:snomedCT.code | required | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | ||||
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIPcodeshttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-NICIP from this IG | ||||
DiagnosticReport.code.coding:loinc.code | required | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.presentedForm.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | UKCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
noteR5 | 0..* | (Complex) | Comments about the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note" | |||||
value[x] | 1..1 | Annotation | Comments about the diagnostic report. | |||||
supportingInfoR5 | 0..* | (Complex) | Additional info supporting the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-diagnosticReport-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnosticReport Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
basedOn | 0..* | Reference(InterweaveCarePlan | InterweaveMedicationRequest | InterweaveServiceRequest) | What was requested | |||||
status | ?!SΣ | 1..1 | code | The status of the diagnostic report. Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | SΣ | 1..1 | CodeableConcept | A code that classifies the clinical discipline, department or diagnostic service that created the report. Binding: DiagnosticServiceSectionCodes (required) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | SΣ | 1..1 | CodeableConcept | A code or name that describes this diagnostic report. Binding: UK Core Report Code (preferred) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:coding.system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | SNOMED CT Clinical Procedure Report code Binding: UK Core Report Code (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/CodeSystem/Interweave-NICIP | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIPcodes (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | LOINC code Binding: LOINCDiagnosticReportCodes (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | 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 | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
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 | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | 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 | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
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 | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for report | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 1..1 | instant | Clinically relevant time / time-period for report. | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
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 | |||||
deviceReference | 0..1 | Reference(Device) | A reference to a Device which interprets / performs the results of the DiagnosticReport. URL: https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-DeviceReference | |||||
reference | ΣC | 0..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 | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(Observation) | Observations that are part of this diagnostic report. | ||||
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 | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
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 | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |||||
media | Σ | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | ||||
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 | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): Diagnosis codes provided as adjuncts to the report. | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
data | 0..1 | base64Binary | Data inline, base64ed | |||||
url | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DiagnosticReport.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.identifier:localIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.category | required | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | ||||
DiagnosticReport.code.coding:snomedCT.code | required | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | ||||
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIPcodeshttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-NICIP from this IG | ||||
DiagnosticReport.code.coding:loinc.code | required | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DiagnosticReport.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DiagnosticReport.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DiagnosticReport.resultsInterpreter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DiagnosticReport.result.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard | ||||
DiagnosticReport.presentedForm.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.presentedForm.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages 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 UKCoreDiagnosticReport
Summary
Mandatory: 5 elements(26 nested mandatory elements)
Must-Support: 25 elements
Fixed: 6 elements
Prohibited: 8 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from UKCoreDiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | UKCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | Content/Rules for all slices | |||
extension:compositionReferenceR5 | 0..0 | |||
Slices for identifier | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | |
identifier:All Slices | Content/Rules for all slices | |||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
identifier:localIdentifier | S | 0..1 | Identifier | Business identifier for report |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-diagnosticReport-identifier |
value | S | 1..1 | string | The Local diagnosticReport Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
basedOn | 0..* | Reference(InterweaveCarePlan | InterweaveMedicationRequest | InterweaveServiceRequest) | What was requested | |
category | 1..1 | CodeableConcept | A code that classifies the clinical discipline, department or diagnostic service that created the report. Binding: DiagnosticServiceSectionCodes (required) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
code | ||||
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:coding.system | |
coding:snomedCT | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
code | S | 1..1 | code | SNOMED CT Clinical Procedure Report code Binding: UK Core Report Code (required) |
display | S | 1..1 | string | Representation defined by the system |
coding:nicip | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/CodeSystem/Interweave-NICIP |
code | S | 1..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIPcodes (required) |
display | S | 1..1 | string | Representation defined by the system |
coding:loinc | 0..1 | Coding | Code defined by a terminology system | |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | S | 1..1 | code | LOINC code Binding: LOINCDiagnosticReportCodes (required) |
display | S | 1..1 | string | Representation defined by the system |
subject | 1..1 | Reference(InterweavePatient) | The subject of the report - usually, but not always, the patient. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
encounter | 0..1 | Reference(InterweaveEncounter) | Health care event when test ordered. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
effective[x] | S | 0..1 | dateTime, Period | Clinically relevant time/time-period for report |
issued | 1..1 | instant | Clinically relevant time / time-period for report. | |
resultsInterpreter | 0..0 | |||
result | ||||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
imagingStudy | 0..* | Reference(ImagingStudy) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
media | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
conclusionCode | ||||
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
presentedForm | S | 0..* | Attachment | Entire report as issued |
contentType | S | 1..1 | code | Mime type of the content, with charset etc. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.category | required | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code.coding:snomedCT.code | required | UKCoreReportCodehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/UKCore-ReportCode from this IG | |
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIPcodeshttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-NICIP from this IG | |
DiagnosticReport.code.coding:loinc.code | required | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | UKCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
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text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | Content/Rules for all slices | |||||||
noteR5 | 0..* | (Complex) | Comments about the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note" | |||||
value[x] | 1..1 | Annotation | Comments about the diagnostic report. | |||||
supportingInfoR5 | 0..* | (Complex) | Additional info supporting the diagnostic report. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-diagnosticReport-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnosticReport Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
basedOn | 0..* | Reference(InterweaveCarePlan | InterweaveMedicationRequest | InterweaveServiceRequest) | What was requested | |||||
status | ?!SΣ | 1..1 | code | The status of the diagnostic report. Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | SΣ | 1..1 | CodeableConcept | A code that classifies the clinical discipline, department or diagnostic service that created the report. Binding: DiagnosticServiceSectionCodes (required) | ||||
code | SΣ | 1..1 | CodeableConcept | A code or name that describes this diagnostic report. Binding: UK Core Report Code (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:coding.system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | SΣ | 1..1 | code | SNOMED CT Clinical Procedure Report code Binding: UK Core Report Code (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/CodeSystem/Interweave-NICIP | ||||
code | SΣ | 1..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIPcodes (required) | ||||
display | SΣ | 1..1 | string | Representation defined by the system | ||||
coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||