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 R4 profiles here.
Official URL: https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-DiagnosticReport | Version: 0.1.0 | |||
Active as of 2024-07-17 | Computable Name: InterweaveDiagnosticReport |
Interweave Diagnostic Report resource profile.
Status: Active: Approved (STU)
This profile sets minimum expectations for the Diagnostic Report resource. As noted in the FHIR specifications, a Diagnostic Report allows for presenting a combination of:
The following mandatory fields are defined for a Diagnostic Report:
Status - 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 - 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 - 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 - CareConnect 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” - ie 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
Effective date - important date to provide details of the clinically relevant period, where relevant (eg based on when specimens taken - see FHIR guidance notes for further details)
Context - 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
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/tiff (no longer supported and is not recommended for web use)
- 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.
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
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:
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.
Coded Diagnosis - this is in effect the “conclusion” in coded form (In FHIR R4 this field is renamed as “conclusionCode”). 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
Specimen - if relevant and available then details of the specimen should be provided
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).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CareConnect-DiagnosticReport-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | CareConnect-DiagnosticReport-1 | 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 | ||||
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..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
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 |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
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 |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
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 identifier | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | |
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.yhcr.nhs.uk/Id/local-diagnostic-report-identifier |
value | S | 1..1 | string | The Local diagnostic-report Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
status | S | 1..1 | code | registered | partial | preliminary | final + |
category | S | 1..1 | CodeableConcept | Service category Binding: Diagnostic Service Section Codes (required) |
coding | 0..* | Coding | Code defined by a terminology system | |
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 | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Care Connect Report Code SnCT (preferred) |
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
coding:All Slices | Content/Rules for all slices | |||
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 | |
coding:nicip | 0..1 | Coding | Code defined by a terminology system | |
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: https://fhir.yhcr.nhs.uk/CodeSystem/Interweave-NICIP-1 |
code | S | 0..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIP codes (required) |
display | S | 0..1 | string | Representation defined by the system |
coding:loinc | 0..1 | Coding | Code defined by a terminology system | |
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | S | 0..1 | code | LOINC code Binding: LOINC Diagnostic Report Codes (required) |
display | S | 0..1 | string | Representation defined by the system |
subject | S | 1..1 | Reference(CareConnectPatient1) | The subject of the report - for our purposes 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 | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | 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 | S | 1..1 | instant | DateTime this version was released |
result | S | 0..* | Reference(CareConnect-Observation-1) | Observations - simple, or complex nested groups |
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 | ImagingManifest) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
image | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
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 |
DiagnosticReport.category | required | Diagnostic Service Section Codes |
DiagnosticReport.code | preferred | Care Connect Report Code SnCT |
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIP codes |
DiagnosticReport.code.coding:loinc.code | required | LOINC Diagnostic Report Codes (a valid code from LOINC) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | CareConnect-DiagnosticReport-1 | 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..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
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: Common Tags (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: Common Tags (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://yhcr.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: Common Tags (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://yhcr.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: Common Languages (extensible): 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 | |||||
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 (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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.yhcr.nhs.uk/Id/local-diagnostic-report-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnostic-report Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report as a whole. | ||||
category | SΣ | 1..1 | CodeableConcept | Service category Binding: Diagnostic Service Section Codes (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Care Connect Report Code SnCT (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system Binding: Care Connect Report Code SnCT (extensible): A code from the SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 0..1 | uri | Identity of the terminology system Fixed Value: https://fhir.yhcr.nhs.uk/CodeSystem/Interweave-NICIP-1 | ||||
code | SΣ | 0..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIP codes (required) | ||||
display | SΣ | 0..1 | string | Representation defined by the system | ||||
coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
code | SΣ | 0..1 | code | LOINC code Binding: LOINC Diagnostic Report Codes (required) | ||||
display | SΣ | 0..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | The subject of the report - for our purposes 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 | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | 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 | DateTime this version was released | ||||
result | S | 0..* | Reference(CareConnect-Observation-1) | Observations - simple, or complex nested groups | ||||
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 | ImagingManifest) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |||||
image | 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 | ||||
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: mimetypes (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 | ||||
DiagnosticReport.meta.security | extensible | All Security Labels | ||||
DiagnosticReport.meta.tag | example | Common Tags | ||||
DiagnosticReport.meta.tag:Source | example | Common Tags | ||||
DiagnosticReport.meta.tag:Provenance | example | Common Tags | ||||
DiagnosticReport.language | extensible | Common Languages
| ||||
DiagnosticReport.identifier.use | required | IdentifierUse | ||||
DiagnosticReport.identifier:localIdentifier.use | required | IdentifierUse | ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | required | Diagnostic Service Section Codes | ||||
DiagnosticReport.code | preferred | Care Connect Report Code SnCT | ||||
DiagnosticReport.code.coding:snomedCT | extensible | Care Connect Report Code SnCT | ||||
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIP codes | ||||
DiagnosticReport.code.coding:loinc.code | required | LOINC Diagnostic Report Codes (a valid code from LOINC) | ||||
DiagnosticReport.presentedForm.contentType | required | http://hl7.org/fhir/ValueSet/mimetypes |
Id | Grade | Path(s) | Details | Requirements |
dom-1 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
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 : contained.where(('#'+id in %resource.descendants().reference).not()).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() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | CareConnect-DiagnosticReport-1 | 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 | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
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: Common Tags (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: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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://yhcr.nhs.uk/Source | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
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: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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://yhcr.nhs.uk/Provenance | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
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: Common Languages (extensible): 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 | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
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 | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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 | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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.yhcr.nhs.uk/Id/local-diagnostic-report-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnostic-report Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
basedOn | 0..* | Reference(CareConnect-CarePlan-1 | CareConnect-MedicationRequest-1 | CareConnect-ReferralRequest-1 | CareConnect-ProcedureRequest-1) | What was requested | |||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report as a whole. | ||||
category | SΣ | 1..1 | CodeableConcept | Service category Binding: Diagnostic Service Section Codes (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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 | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 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 | 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 | Name/Code for this diagnostic report Binding: Care Connect Report Code SnCT (preferred) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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 | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system Binding: Care Connect Report Code SnCT (extensible): A code from the SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 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 | 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 | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 0..1 | uri | Identity of the terminology system Fixed Value: https://fhir.yhcr.nhs.uk/CodeSystem/Interweave-NICIP-1 | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 0..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIP codes (required) | ||||
display | SΣ | 0..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 | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 0..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 | 0..1 | code | LOINC code Binding: LOINC Diagnostic Report Codes (required) | ||||
display | SΣ | 0..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(CareConnectPatient1) | The subject of the report - for our purposes the patient | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Health care event when test ordered | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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) | ||||
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 | DateTime this version was released | ||||
performer | Σ | 0..* | BackboneElement | Participants in producing the report | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
role | Σ | 0..1 | CodeableConcept | Type of performer Binding: Procedure Performer Role Codes (example): Indicate a role of diagnostic report performer | ||||
actor | Σ | 1..1 | Reference(CareConnect-Organization-1 | CareConnect-Practitioner-1) | Practitioner or Organization participant | ||||
specimen | 0..* | Reference(CareConnect-Specimen-1) | Specimens this report is based on | |||||
result | S | 0..* | Reference(CareConnect-Observation-1) | Observations - simple, or complex nested groups | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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) | ||||
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 | ImagingManifest) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |||||
image | Σ | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
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 Interpretation of test results | |||||
codedDiagnosis | 0..* | CodeableConcept | Codes for the conclusion Binding: Care Connect Finding Code (preferred): A SNOMED Coded finding for the test report. | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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:system | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system Binding: Care Connect Finding Code (extensible): A code from the SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 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 | 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 | xml:id (or equivalent in JSON) | |||||
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: mimetypes (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: Common Languages (extensible): A human language.
Example General: en-AU | ||||
data | 0..1 | base64Binary | Data inline, base64ed | |||||
url | Σ | 0..1 | uri | 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 | ||||
DiagnosticReport.meta.security | extensible | All Security Labels | ||||
DiagnosticReport.meta.tag | example | Common Tags | ||||
DiagnosticReport.meta.tag:Source | example | Common Tags | ||||
DiagnosticReport.meta.tag:Provenance | example | Common Tags | ||||
DiagnosticReport.language | extensible | Common Languages
| ||||
DiagnosticReport.identifier.use | required | IdentifierUse | ||||
DiagnosticReport.identifier.type | extensible | Identifier Type Codes | ||||
DiagnosticReport.identifier:localIdentifier.use | required | IdentifierUse | ||||
DiagnosticReport.identifier:localIdentifier.type | extensible | Identifier Type Codes | ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | required | Diagnostic Service Section Codes | ||||
DiagnosticReport.code | preferred | Care Connect Report Code SnCT | ||||
DiagnosticReport.code.coding:snomedCT | extensible | Care Connect Report Code SnCT | ||||
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIP codes | ||||
DiagnosticReport.code.coding:loinc.code | required | LOINC Diagnostic Report Codes (a valid code from LOINC) | ||||
DiagnosticReport.performer.role | example | Procedure Performer Role Codes | ||||
DiagnosticReport.codedDiagnosis | preferred | Care Connect Finding Code | ||||
DiagnosticReport.codedDiagnosis.coding:snomedCT | extensible | Care Connect Finding Code | ||||
DiagnosticReport.presentedForm.contentType | required | http://hl7.org/fhir/ValueSet/mimetypes | ||||
DiagnosticReport.presentedForm.language | extensible | Common Languages
|
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |
This structure is derived from CareConnect-DiagnosticReport-1
Summary
Mandatory: 4 elements (15 nested mandatory elements)
Must-Support: 29 elements
Fixed Value: 5 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CareConnect-DiagnosticReport-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | CareConnect-DiagnosticReport-1 | 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 | ||||
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..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
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 |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
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 |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
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 identifier | 0..* | Identifier | Business identifier for report Slice: Unordered, Open by value:system | |
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.yhcr.nhs.uk/Id/local-diagnostic-report-identifier |
value | S | 1..1 | string | The Local diagnostic-report Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
status | S | 1..1 | code | registered | partial | preliminary | final + |
category | S | 1..1 | CodeableConcept | Service category Binding: Diagnostic Service Section Codes (required) |
coding | 0..* | Coding | Code defined by a terminology system | |
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 | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Care Connect Report Code SnCT (preferred) |
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
coding:All Slices | Content/Rules for all slices | |||
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 | |
coding:nicip | 0..1 | Coding | Code defined by a terminology system | |
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: https://fhir.yhcr.nhs.uk/CodeSystem/Interweave-NICIP-1 |
code | S | 0..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIP codes (required) |
display | S | 0..1 | string | Representation defined by the system |
coding:loinc | 0..1 | Coding | Code defined by a terminology system | |
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | S | 0..1 | code | LOINC code Binding: LOINC Diagnostic Report Codes (required) |
display | S | 0..1 | string | Representation defined by the system |
subject | S | 1..1 | Reference(CareConnectPatient1) | The subject of the report - for our purposes 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 | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | 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 | S | 1..1 | instant | DateTime this version was released |
result | S | 0..* | Reference(CareConnect-Observation-1) | Observations - simple, or complex nested groups |
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 | ImagingManifest) | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
image | 0..* | BackboneElement | DISCOURAGED: Intention is primarily to share reports and results, not raw images. Will be ignored if populated. | |
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 |
DiagnosticReport.category | required | Diagnostic Service Section Codes |
DiagnosticReport.code | preferred | Care Connect Report Code SnCT |
DiagnosticReport.code.coding:nicip.code | required | InterweaveNICIP codes |
DiagnosticReport.code.coding:loinc.code | required | LOINC Diagnostic Report Codes (a valid code from LOINC) |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | CareConnect-DiagnosticReport-1 | 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..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
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: Common Tags (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: Common Tags (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://yhcr.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: Common Tags (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://yhcr.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: Common Languages (extensible): 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 | |||||
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 (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Business identifier for report | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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.yhcr.nhs.uk/Id/local-diagnostic-report-identifier | ||||
value | SΣ | 1..1 | string | The Local diagnostic-report Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report as a whole. | ||||
category | SΣ | 1..1 | CodeableConcept | Service category Binding: Diagnostic Service Section Codes (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Care Connect Report Code SnCT (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..* | Coding | Code defined by a terminology system Binding: Care Connect Report Code SnCT (extensible): A code from the SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:nicip | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 0..1 | uri | Identity of the terminology system Fixed Value: https://fhir.yhcr.nhs.uk/CodeSystem/Interweave-NICIP-1 | ||||
code | SΣ | 0..1 | code | National Interim Clinical Imaging Procedure code Binding: InterweaveNICIP codes (required) | ||||
display | SΣ | 0..1 | string | Representation defined by the system | ||||
coding:loinc | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
system | SΣ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
code | SΣ | 0..1 | code | LOINC code Binding: LOINC Diagnostic Report Codes (required) | ||||
display | SΣ | 0..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | The subject of the report - for our purposes 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 | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | 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 |