CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
This page is part of the CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG (v1.0.0: Release) based on FHIR (HL7? FHIR? Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://www.cy118119.com/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-daily-diagnosticreport-lab | Version: 1.0.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalDailyEventLabDiagnosticReport | ||
This profile contains Required and Must Support data elements for reporting diagnostic report lab information for the NHSN Acute Care Hospital (ACH) Daily Digital Quality Measure. This profile is based on the HL7 FHIR? US Core Diagnostic Report - Lab Profile v3.1.1.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) |
  Slices for category |
SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
   category:LaboratorySlice |
SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
  id |
0..1 | string | Unique id for inter-element referencing | |
 extension |
0..* | Extension | Additional content defined by implementations | |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
| display |
0..1 | string | Representation defined by the system | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
 text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
 subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 effective[x] |
SΣ | 1..1 | Specimen Collection Datetime or Period | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 1..1 | instant | DateTime this version was made |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom 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 USCoreDiagnosticReportProfileLaboratoryReporting
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 id |
1..1 | id | Logical id of this artifact | |
| meta |
||||
 Slices for extension |
Content/Rules for all slices | |||
 extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cy118119.com/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |
| status |
1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Health care event when test ordered |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
 Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cy118119.com/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) | ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:LaboratorySlice |
SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣ | 1..1 | Specimen Collection Datetime or Period | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 1..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results | ||||
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | ||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.specimen.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom 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 USCoreDiagnosticReportProfileLaboratoryReporting
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 7 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) |
| Slices for category |
SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| category:LaboratorySlice |
SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
SΣ | 1..1 | Specimen Collection Datetime or Period | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 1..1 | instant | DateTime this version was made |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| id |
1..1 | id | Logical id of this artifact | |
| meta |
||||
| Slices for extension |
Content/Rules for all slices | |||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cy118119.com/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |
| status |
1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Health care event when test ordered |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cy118119.com/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | final | registered | preliminary | partial Binding: ACH Daily Diagnostic Report Status ValueSet (required) | ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:LaboratorySlice |
SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣ | 1..1 | Specimen Collection Datetime or Period | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 1..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
S | 0..* | Reference(Specimen) | Specimens this report is based on | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| result |
S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations | ||||
| imagingStudy |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | Clinical conclusion (interpretation) of test results | ||||
| conclusionCode |
S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | ||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.status | required | AcuteCareHospitalDailyEventDiagnosticReportStatushttp://www.cy118119.com/nhsn/fhirportal/dqm/ig/ValueSet/ach-daily-diagnostic-report-statusFrom this IG | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.specimen.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsFrom 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 USCoreDiagnosticReportProfileLaboratoryReporting
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 7 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
