FHIR Implementation Guide for NDHM CI Build v1.2
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NDHM (R4), Published and maintained by NRCeS for NHA.
This version is based on the NDHM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-DiagnosticReportRecord

This profile sets minimum expectations for the DiagnosticReportRecord that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation to a Diagnostic Report of a patient. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

This profile builds on Composition

Summary

Mandatory: 8 elements (6 nested mandatory elements)
Must-Support: 10 elements
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section.entry is sliced based on the value of value:type (Closed)
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... coding 1..1CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... author S1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
...... display 1..1stringRepresentation defined by the system
..... text S0..1stringPlain text representation of the concept
.... entry S1..2(Slice Definition)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReportLab 0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: DiagnosticReport
..... entry:DocumentReference 0..1Reference(DocumentReference)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: DocumentReference

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record.
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣI1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
..... display ΣI1..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text SΣI0..1stringPlain text representation of the concept
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣI1..1Reference(Patient)Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... encounter ΣI0..1Reference(Encounter)Context of the Composition
... date ΣI1..1dateTimeComposition editing time
... author SΣI1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... title ΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required)
... attester SI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodThe period covered by the documentation
.... detail ΣI0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version ΣI0..1stringVersion of the system - if relevant
...... code ΣI1..1codeSymbol in syntax defined by the system
...... display ΣI1..1stringRepresentation defined by the system
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text SΣI0..1stringPlain text representation of the concept
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
.... entry SI1..2(Slice Definition)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReportLab I0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type ΣI1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
Fixed Value: DiagnosticReport
...... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
...... display ΣI0..1stringText alternative for the resource
..... entry:DocumentReference I0..1Reference(DocumentReference)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type ΣI1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
Fixed Value: DocumentReference
...... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
...... display ΣI0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
.... section I0..*See sectionNested Section

doco Documentation for this format

Summary

Mandatory: 8 elements (6 nested mandatory elements)
Must-Support: 10 elements
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section.entry is sliced based on the value of value:type (Closed)

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... coding 1..1CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... author S1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
...... display 1..1stringRepresentation defined by the system
..... text S0..1stringPlain text representation of the concept
.... entry S1..2(Slice Definition)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReportLab 0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: DiagnosticReport
..... entry:DocumentReference 0..1Reference(DocumentReference)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: DocumentReference

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record.
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣI1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
..... display ΣI1..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text SΣI0..1stringPlain text representation of the concept
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣI1..1Reference(Patient)Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... encounter ΣI0..1Reference(Encounter)Context of the Composition
... date ΣI1..1dateTimeComposition editing time
... author SΣI1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... title ΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required)
... attester SI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodThe period covered by the documentation
.... detail ΣI0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version ΣI0..1stringVersion of the system - if relevant
...... code ΣI1..1codeSymbol in syntax defined by the system
...... display ΣI1..1stringRepresentation defined by the system
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text SΣI0..1stringPlain text representation of the concept
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
.... entry SI1..2(Slice Definition)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReportLab I0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type ΣI1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
Fixed Value: DiagnosticReport
...... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
...... display ΣI0..1stringText alternative for the resource
..... entry:DocumentReference I0..1Reference(DocumentReference)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type ΣI1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
Fixed Value: DocumentReference
...... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
...... display ΣI0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
.... section I0..*See sectionNested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron