Laboratory Workflows Implementation Guide
0.3.0 - ci-build
Laboratory Workflows Implementation Guide
0.3.0 - ci-build
Laboratory Workflows Implementation Guide - Local Development build (v0.3.0). See the Directory of published versions
| Official URL: http://i-tech-uw.github.io/laboratory-workflows-ig/StructureDefinition/laboratory-diagnostic-report | Version: 0.3.0 | |||
| Active as of 2022-08-16 | Responsible: I-TECH-UW | Computable Name: LaboratoryDiagnosticReport | ||
DiagnosticReport resource created by a LIS that representing results of an order submitted from an EMR System
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReportUvIps
This structure is derived from DiagnosticReportUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReportUvIps | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  status | 1..1 | code | registered | partial | preliminary | final + Binding: Laboratory Diagnostic Report Status Flag (required) | |
 code | ||||
  coding | 1..* | CodingIPS | A reference to a code defined by a terminology system Binding: EMR Lab Order Code (required) | |
 result | 0..* | Reference(Laboratory Observation) | Observation results included in the diagnostic report. | |
 result:observation-results | 0..* | Reference(Laboratory Observation) | Observations | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | S | 0..* | DiagnosticReportUvIps | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
 id | Σ | 0..1 | string | Logical id of this artifact | ||||
 meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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 | |||||
| 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 | registered | partial | preliminary | final + Binding: Laboratory Diagnostic Report Status Flag (required) Fixed Value: final | ||||
| category | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | S | 1..* | CodingIPS | A reference to a code defined by a terminology system Binding: EMR Lab Order Code (required) | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| subject | SΣ | 1..1 | Reference(Patient (IPS) | Group) | 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 | SΣI | 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 | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
 effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |||||
| effective[x]:All Types | Content/Rules for all Types | |||||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
 data-absent-reason | S | 0..1 | code | effective[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. | ||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | SΣ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on | |||||
 Slices for result | S | 0..* | Reference(Laboratory Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() | ||||
| result:observation-results | S | 0..* | Reference(Laboratory Observation) | Observations | ||||
| imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 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 | ||||||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReportUvIps | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: Laboratory Diagnostic Report Status Flag (required) Fixed Value: final |
| category | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | |
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | |
| coding | 1..* | CodingIPS | A reference to a code defined by a terminology system Binding: EMR Lab Order Code (required) | |
| text | Σ | 0..1 | string | Plain text representation of the concept |
| subject | Σ | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] | Σ | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]:All Types | Content/Rules for all Types | |||
| data-absent-reason | 0..1 | code | effective[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. | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| performer | Σ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service |
 Slices for result | 0..* | Reference(Laboratory Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() | |
 result:observation-results | 0..* | Reference(Laboratory Observation) | Observations | |
| Documentation for this format | ||||
This structure is derived from DiagnosticReportUvIps
Differential View
This structure is derived from DiagnosticReportUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReportUvIps | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| status | 1..1 | code | registered | partial | preliminary | final + Binding: Laboratory Diagnostic Report Status Flag (required) | |
| code | ||||
| coding | 1..* | CodingIPS | A reference to a code defined by a terminology system Binding: EMR Lab Order Code (required) | |
| result | 0..* | Reference(Laboratory Observation) | Observation results included in the diagnostic report. | |
| result:observation-results | 0..* | Reference(Laboratory Observation) | Observations | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | S | 0..* | DiagnosticReportUvIps | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
| id | Σ | 0..1 | string | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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 | |||||
| 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 | registered | partial | preliminary | final + Binding: Laboratory Diagnostic Report Status Flag (required) Fixed Value: final | ||||
| category | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | S | 1..* | CodingIPS | A reference to a code defined by a terminology system Binding: EMR Lab Order Code (required) | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| subject | SΣ | 1..1 | Reference(Patient (IPS) | Group) | 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 | SΣI | 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 | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |||||
| effective[x]:All Types | Content/Rules for all Types | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| data-absent-reason | S | 0..1 | code | effective[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. | ||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | SΣ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on | |||||
| Slices for result | S | 0..* | Reference(Laboratory Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() | ||||
| result:observation-results | S | 0..* | Reference(Laboratory Observation) | Observations | ||||
| imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
| media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 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 | ||||||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
| DiagnosticReport.status | required | Fixed Value: final |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes |
| DiagnosticReport.code.coding | required | LaboratoryOrderCodeVS |
| DiagnosticReport.subject.type | extensible | ResourceType |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| Id | Grade | Path | 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 | DiagnosticReport.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.code.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.code.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.code.coding | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.code.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.subject.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.subject.reference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject.display | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.effective[x].extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.effective[x].extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.resultsInterpreter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.specimen | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.result | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.result:observation-results | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.imagingStudy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.media.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.media.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.media.comment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media.link | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.conclusion | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.presentedForm | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2021+ I-TECH-UW. Package laboratory.workflows.ig#0.3.0 based on FHIR 4.0.1. Generated 2022-08-16
Links: Table of Contents |
QA Report |
Version History |
|