EMR-LIS Implementation Guide
0.2.0 - ci-build

EMR-LIS Implementation Guide - Local Development build (v0.2.0). See the Directory of published versions

Resource Profile: EMR-LIS Diagnostic Report

Defining URL:http://i-tech-uw.github.io/emr-lis-ig/StructureDefinition/emr-lab-diagnostic-report
Version:0.2.0
Name:EmrLisDiagnosticReport
Title:EMR-LIS Diagnostic Report
Status:Active as of 2021-07-27T07:51:26+00:00
Definition:

DiagnosticReport resource created by a LIS that representing results of an order submitted from an EMR System

Publisher:I-TECH-UW
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://i-tech-uw.github.io/emr-lis-ig/StructureDefinition/emr-lab-diagnostic-report

Formal Views of Profile Content

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

This structure is derived from DiagnosticReportUvIps

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

This structure is derived from DiagnosticReportUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportUvIpsA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1coderegistered | partial | preliminary | final +
Binding: EMR-LIS Diagnostic Report Status Flag (required)
... code
.... coding 1..*CodingIPSA reference to a code defined by a terminology system
Binding: EMR Lab Order Code (required)
... result 0..*Reference(EMR-LIS Observation)Observation results included in the diagnostic report.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport S0..*DiagnosticReportUvIpsA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: EMR-LIS Diagnostic Report Status Flag (required)
Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding S1..*CodingIPSA reference to a code defined by a terminology system
Binding: EMR Lab Order Code (required)
.... text SΣ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(EMR-LIS Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:$this.resolve()
.... result:observation-results S0..*Reference(EMR-LIS Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportUvIpsA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: EMR-LIS Diagnostic Report Status Flag (required)
Fixed Value: final
... category 1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code 1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... coding 1..*CodingIPSA reference to a code defined by a terminology system
Binding: EMR Lab Order Code (required)
.... text Σ0..1stringPlain text representation of the concept
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
... effective[x] Σ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason 0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... performer Σ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... Slices for result 0..*Reference(EMR-LIS Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:$this.resolve()
.... result:observation-results 0..*Reference(EMR-LIS Observation)Observations

doco Documentation for this format

This structure is derived from DiagnosticReportUvIps

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DiagnosticReportUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportUvIpsA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1coderegistered | partial | preliminary | final +
Binding: EMR-LIS Diagnostic Report Status Flag (required)
... code
.... coding 1..*CodingIPSA reference to a code defined by a terminology system
Binding: EMR Lab Order Code (required)
... result 0..*Reference(EMR-LIS Observation)Observation results included in the diagnostic report.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport S0..*DiagnosticReportUvIpsA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: EMR-LIS Diagnostic Report Status Flag (required)
Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding S1..*CodingIPSA reference to a code defined by a terminology system
Binding: EMR Lab Order Code (required)
.... text SΣ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(EMR-LIS Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:$this.resolve()
.... result:observation-results S0..*Reference(EMR-LIS Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredFixed Value: final
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes
DiagnosticReport.code.codingrequiredEmrLisOrderCodeVS
DiagnosticReport.subject.typeextensibleResourceType
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdPathDetailsRequirements
dom-2DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3DiagnosticReportIf 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-4DiagnosticReportIf 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-5DiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6DiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1DiagnosticReport.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.code.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.code.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.code.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.code.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.subject.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.subject.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.subject.referenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.subject.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.subject.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.subject.displayAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.effective[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.effective[x].extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.effective[x].extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.issuedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.resultsInterpreterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.specimenAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.resultAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.result:observation-resultsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.imagingStudyAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.media.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.media.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.media.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.media.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.media.commentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.media.linkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.conclusionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.conclusionCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1DiagnosticReport.presentedFormAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())