PLUGIN - Local Development build (v0.1.0-ci) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: DiagnosticReport - Pathology

DiagnosticReport as used within PLUGIN for Pathology.

Vergelijking met Epic (@RUMC)

DiagnosticReport.category

Epic stuurt 2 codes:

• Pathologie

  urn:oid:1.2.840.114350.1.13.357.2.7.10.798268.30

• LAB	https://terminology.hl7.org/6.0.2/CodeSystem-v2-0074.html

De code Pathologie maakt gebruik van een codestelsel dat specifiek is voor Epic. Bij voorkeur wordt dit veranderd in PAT of CP.

De code LAB lijkt meer een overkoepelende term voor laboratoria.

DiagnosticReport.code

Epic stuurt 2 codes:

• 67307

  urn:oid:1.2.840.114350.1.13.357.2.7.2.696580

• HISTOLOGIE

  urn:oid:1.2.840.114350.1.13.357.2.7.5.737384.83

Beide codes maken gebruik van een Epic-specifiek OID. De (internationale) FHIR IG benoemt de voorkeur voor LOINC. In Nederland worden (waarschijnlijk) PALGA-codes gebruikt PALGA thesaurus.

DiagnosticReport.result

result bevat momenteel 4 componenten (referenties naar Observations):

• Samenvatting
• Conclusie
• Macroscopie
• Microscopie

Deze componenten zijn (nog) niet gecodeerd.

TODO:

• Voorstel voor selectie PA-verslagen via codes CP en SP uit http://terminology.hl7.org/CodeSystem/v2-0074.

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from NlcoreTextResult

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
basedOn		0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
category		1..*	CodeableConcept	Service category
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
code
text		1..1	string	Plain text representation of the concept
subject		1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient
performer		1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
specimen		1..1	Reference(Specimen)	Specimens this report is based on
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
basedOn	C	0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested ref-1: SHALL have a contained resource if a local reference is provided
status	?!Σ	1..1	code	TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus.
Slices for extension				Content/Rules for all slices
textResultStatus	N	0..1	(Complex)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification
url		1..1	uri	"http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification"
category	Σ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode	Σ	1..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
code	Σ	1..1	CodeableConcept	TextResultType Binding: TekstUitslagTypeCodelijst (extensible): Codes that describe Diagnostic Reports.
text	Σ	1..1	string	Plain text representation of the concept
subject	ΣC	1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient ref-1: SHALL have a contained resource if a local reference is provided
Slices for effective[x]	ΣN	0..1		Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effective[x]:effectiveDateTime	ΣN	0..1	dateTime	TextResultDateTime
performer	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service ref-1: SHALL have a contained resource if a local reference is provided
specimen	C	1..1	Reference(Specimen)	Specimens this report is based on ref-1: SHALL have a contained resource if a local reference is provided
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes	Σ	1..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG
DiagnosticReport.code	extensible	TekstUitslagTypeCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

Constraints

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()
ref-1	error	DiagnosticReport.basedOn, DiagnosticReport.subject, DiagnosticReport.performer, DiagnosticReport.specimen	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
id	Σ	0..1	id	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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	0..*	Identifier	Business identifier for report
basedOn	C	0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested ref-1: SHALL have a contained resource if a local reference is provided
status	?!Σ	1..1	code	TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus.
id		0..1	string	Unique id for inter-element referencing
Slices for extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
textResultStatus	N	0..1	(Complex)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification"
value[x]	N	0..1	CodeableConcept	TextResultStatus Binding: TekstStatusCodelijst (extensible)
value		0..1	code	Primitive value for code Max Length: 1048576
category	Σ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
display	Σ	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
code	Σ	1..1	CodeableConcept	TextResultType Binding: TekstUitslagTypeCodelijst (extensible): 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	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	1..1	string	Plain text representation of the concept
subject	ΣC	1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient ref-1: SHALL have a contained resource if a local reference is provided
encounter	ΣC	0..1	Reference(Encounter)	Health care event when test ordered ref-1: SHALL have a contained resource if a local reference is provided
Slices for effective[x]	ΣN	0..1		Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effective[x]:effectiveDateTime	ΣN	0..1	dateTime	TextResultDateTime
issued	Σ	0..1	instant	DateTime this version was made
performer	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service ref-1: SHALL have a contained resource if a local reference is provided
resultsInterpreter	ΣC	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter ref-1: SHALL have a contained resource if a local reference is provided
specimen	C	1..1	Reference(Specimen)	Specimens this report is based on ref-1: SHALL have a contained resource if a local reference is provided
result	C	0..*	Reference(Observation)	Observations ref-1: SHALL have a contained resource if a local reference is provided
imagingStudy	C	0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report ref-1: SHALL have a contained resource if a local reference is provided
media	Σ	0..*	BackboneElement	Key images associated with this report
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
comment		0..1	string	Comment about the image (e.g. explanation)
link	ΣC	1..1	Reference(Media | nl core TextResult.VisualResult)	Reference to the image source ref-1: SHALL have a contained resource if a local reference is provided
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
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	C	0..*	Attachment	Entire report as issued att-1: If the Attachment has data, it SHALL have a contentType
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.status.extension:textResultStatus.value[x]	extensible	TekstStatusCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG
DiagnosticReport.code	extensible	TekstUitslagTypeCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DiagnosticReport.presentedForm	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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()
ref-1	error	DiagnosticReport.basedOn, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.imagingStudy, DiagnosticReport.media.link	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from NlcoreTextResult

Summary

Mandatory: 16 elements

Structures

This structure refers to these other structures:

• nl core Patient (http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient)
• Patient (https://plugin.healthcare/fhir/StructureDefinition/plugin-patient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DiagnosticReport.category.coding
• The element 1 is sliced based on the value of DiagnosticReport.conclusionCode.coding

Differential View

This structure is derived from NlcoreTextResult

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
basedOn		0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
category		1..*	CodeableConcept	Service category
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
code
text		1..1	string	Plain text representation of the concept
subject		1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient
performer		1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
specimen		1..1	Reference(Specimen)	Specimens this report is based on
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
basedOn	C	0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested ref-1: SHALL have a contained resource if a local reference is provided
status	?!Σ	1..1	code	TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus.
Slices for extension				Content/Rules for all slices
textResultStatus	N	0..1	(Complex)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification
url		1..1	uri	"http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification"
category	Σ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode	Σ	1..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
code	Σ	1..1	CodeableConcept	TextResultType Binding: TekstUitslagTypeCodelijst (extensible): Codes that describe Diagnostic Reports.
text	Σ	1..1	string	Plain text representation of the concept
subject	ΣC	1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient ref-1: SHALL have a contained resource if a local reference is provided
Slices for effective[x]	ΣN	0..1		Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effective[x]:effectiveDateTime	ΣN	0..1	dateTime	TextResultDateTime
performer	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service ref-1: SHALL have a contained resource if a local reference is provided
specimen	C	1..1	Reference(Specimen)	Specimens this report is based on ref-1: SHALL have a contained resource if a local reference is provided
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes	Σ	1..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG
DiagnosticReport.code	extensible	TekstUitslagTypeCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

Constraints

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()
ref-1	error	DiagnosticReport.basedOn, DiagnosticReport.subject, DiagnosticReport.performer, DiagnosticReport.specimen	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	NlcoreTextResult	TextResult
id	Σ	0..1	id	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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	0..*	Identifier	Business identifier for report
basedOn	C	0..1	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested ref-1: SHALL have a contained resource if a local reference is provided
status	?!Σ	1..1	code	TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus.
id		0..1	string	Unique id for inter-element referencing
Slices for extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
textResultStatus	N	0..1	(Complex)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification"
value[x]	N	0..1	CodeableConcept	TextResultStatus Binding: TekstStatusCodelijst (extensible)
value		0..1	code	Primitive value for code Max Length: 1048576
category	Σ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:serviceCode	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: Pathology Report codes (required)
display	Σ	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
code	Σ	1..1	CodeableConcept	TextResultType Binding: TekstUitslagTypeCodelijst (extensible): 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	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	1..1	string	Plain text representation of the concept
subject	ΣC	1..1	Reference(Patient | nl core Patient | Patient)	The subject of the report - usually, but not always, the patient ref-1: SHALL have a contained resource if a local reference is provided
encounter	ΣC	0..1	Reference(Encounter)	Health care event when test ordered ref-1: SHALL have a contained resource if a local reference is provided
Slices for effective[x]	ΣN	0..1		Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effective[x]:effectiveDateTime	ΣN	0..1	dateTime	TextResultDateTime
issued	Σ	0..1	instant	DateTime this version was made
performer	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service ref-1: SHALL have a contained resource if a local reference is provided
resultsInterpreter	ΣC	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter ref-1: SHALL have a contained resource if a local reference is provided
specimen	C	1..1	Reference(Specimen)	Specimens this report is based on ref-1: SHALL have a contained resource if a local reference is provided
result	C	0..*	Reference(Observation)	Observations ref-1: SHALL have a contained resource if a local reference is provided
imagingStudy	C	0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report ref-1: SHALL have a contained resource if a local reference is provided
media	Σ	0..*	BackboneElement	Key images associated with this report
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
comment		0..1	string	Comment about the image (e.g. explanation)
link	ΣC	1..1	Reference(Media | nl core TextResult.VisualResult)	Reference to the image source ref-1: SHALL have a contained resource if a local reference is provided
conclusion		1..1	string	TextResultReport
conclusionCode		1..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:snomedCodes	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: urn:oid:2.16.840.1.113883.2.4.3.23.5.2
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	C	0..*	Attachment	Entire report as issued att-1: If the Attachment has data, it SHALL have a contentType
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.status.extension:textResultStatus.value[x]	extensible	TekstStatusCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.category.coding:serviceCode.code	required	PluginPathologyReportCodes https://plugin.healthcare/fhir/ValueSet/plugin-pa-report-codes-vs from this IG
DiagnosticReport.code	extensible	TekstUitslagTypeCodelijst http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DiagnosticReport.presentedForm	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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()
ref-1	error	DiagnosticReport.basedOn, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.imagingStudy, DiagnosticReport.media.link	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from NlcoreTextResult

Summary

Mandatory: 16 elements

Structures

This structure refers to these other structures:

• nl core Patient (http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient)
• Patient (https://plugin.healthcare/fhir/StructureDefinition/plugin-patient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DiagnosticReport.category.coding
• The element 1 is sliced based on the value of DiagnosticReport.conclusionCode.coding

Other representations of profile: CSV, Excel, Schematron