FHIR Implementation Guide for ABDM
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This page is part of the FHIR Implementation Guide for ABDM (v6.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: StructureDefinition/DiagnosticReportRecord

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportRecord Version: 6.0.0
Draft as of 2020-08-31 Computable Name: DiagnosticReportRecord

The Clinical Artifact represents diagnostic reports including Radiology and Laboratory reports that can be shared across the health ecosystem.

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.

The resources capturing the measurements, tests, panels, observations, interpretation, etc. in Diagnostics domain can use LOINC codes. The guide for using the LOINC codes in the FHIR resources can be found here.

Examples

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.

This structure is derived from Composition

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 1..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
... 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 1..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
.... Slices for entry S1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport 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

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG
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.
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
.... text SΣ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient)Who and/or what the composition is about
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... title Σ1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... section SC1..1BackboneElementComposition is broken into sections
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... coding SΣ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
..... text SΣ0..1stringPlain text representation of the concept
.... Slices for entry SC1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DiagnosticReport
..... entry:DocumentReference C0..1Reference(DocumentReference)A reference to data that supports this section
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DocumentReference

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
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.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section SC1..1BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text SΣ0..1stringPlain text representation of the concept
.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... Slices for entry SC1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DiagnosticReport
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... entry:DocumentReference C0..1Reference(DocumentReference)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DocumentReference
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
Composition.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Composition

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 1..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
... 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 1..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
.... Slices for entry S1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport 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

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG

Key Elements 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.
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
.... text SΣ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient)Who and/or what the composition is about
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... title Σ1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... section SC1..1BackboneElementComposition is broken into sections
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... coding SΣ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
..... text SΣ0..1stringPlain text representation of the concept
.... Slices for entry SC1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DiagnosticReport
..... entry:DocumentReference C0..1Reference(DocumentReference)A reference to data that supports this section
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DocumentReference

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot 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.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson)Who and/or what authored the composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section SC1..1BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text SΣ0..1stringPlain text representation of the concept
.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... Slices for entry SC1..2Reference(DiagnosticReportLab | DiagnosticReportImaging | DocumentReference)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C0..1Reference(DiagnosticReportLab | DiagnosticReportImaging)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DiagnosticReport
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... entry:DocumentReference C0..1Reference(DocumentReference)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: DocumentReference
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredDiagnosticReportType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
Composition.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

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