Resumen Clínico de Paciente de Chile (IPS-CL)
0.2.0 - ci-build
Resumen Clínico de Paciente de Chile (IPS-CL)
0.2.0 - ci-build
This page is part of the Resumen Clinico de Paciente de Chile (v0.2.0: STU1 Draft) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions
| Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/DiagnosticReport-cl-ips | Version: 0.2.0 | |||
| Standards status: Draft | Maturity Level: 1 | Computable Name: DiagnosticReportClIps | ||
Reporte resultado de un o varios estudios para diagnosticar una enfermedad. Este perfil es el simil al DiagnosticReport(IPS).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport |
DiagnosticReport | |||
  status |
S | 1..1 | code | registered | partial | preliminary | final + Required Pattern: final |
 category |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| code |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
  subject |
S | 1..1 | Reference(Paciente (IPS-CL) | Group) | The subject of the report - usually, but not always, the patient |
  reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report |
  Slices for extension |
Content/Rules for all slices | |||
   data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
 value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |
| performer |
S | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter |
S | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter |
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on |
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() |
 result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations |
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | Reference to full details of imaging associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 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 | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: 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. |
| subject |
SΣ | 1..1 | Reference(Paciente (IPS-CL) | Group) | The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 effective[x] |
SΣ | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]All Types |
Content/Rules for all Types | |||
| Slices for extension |
Content/Rules for all slices | |||
| data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
  extension |
0..0 | |||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
| value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| performer |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter |
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on |
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() |
| result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations |
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | Reference to full details of imaging associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom 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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| 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.
| |||||
| 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: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: 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. | ||||
| subject |
SΣ | 1..1 | Reference(Paciente (IPS-CL) | 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 |
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 |
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 | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | ||||
| id |
0..1 | id | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
| value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
Σ | 0..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter | ||||
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on | ||||
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() | ||||
| result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations | ||||
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom 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 DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
DiagnosticReport | |||
| status |
S | 1..1 | code | registered | partial | preliminary | final + Required Pattern: final |
| category |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| code |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| subject |
S | 1..1 | Reference(Paciente (IPS-CL) | Group) | The subject of the report - usually, but not always, the patient |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report |
| Slices for extension |
Content/Rules for all slices | |||
| data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
| value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |
| performer |
S | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter |
S | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter |
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on |
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() |
| result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations |
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | Reference to full details of imaging associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| 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 | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: 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. |
| subject |
SΣ | 1..1 | Reference(Paciente (IPS-CL) | Group) | The subject of the report - usually, but not always, the patient |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
SΣ | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]All Types |
Content/Rules for all Types | |||
| Slices for extension |
Content/Rules for all slices | |||
| data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
| extension |
0..0 | |||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
| value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| performer |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter |
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on |
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() |
| result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations |
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | Reference to full details of imaging associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| DiagnosticReport.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | |
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| 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.
| |||||
| 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: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: 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. | ||||
| subject |
SΣ | 1..1 | Reference(Paciente (IPS-CL) | 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 |
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 |
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 | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| data-absent-reason |
S | 0..1 | (Complex) | Motivo por el cual no se encuentra el dato URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | ||||
| id |
0..1 | id | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
| value[x] |
1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo el dato no se encuentra | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
Σ | 0..1 | instant | DateTime this version was made | ||||
| performer |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter |
SΣ | 0..* | Reference(Prestador Individual (IPS-CL) | Función o Rol de Prestador Individual (IPS-CL) | Organización (IPS-CL) | CareTeam) | Primary result interpreter | ||||
| specimen |
S | 0..* | Reference(Muestra (IPS-CL)) | Specimens this report is based on | ||||
| Slices for result |
S | 0..* | Reference(CL Observación) | Observations Slice: Unordered, Open by profile:resolve() | ||||
| result:observacion-resultados |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL) | Observación Resultado: Imagenológico (IPS-CL)) | Observations | ||||
| imagingStudy |
0..* | Reference(Estudio de Imagenología (IPS-Cl)) | 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codesfrom the FHIR Standard | ||||
| DiagnosticReport.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DiagnosticReport.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom 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 DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron