FHIR Implementation Guide for ABDM
6.5.0 - active India flag

Banner

FHIR Implementation Guide for ABDM - Local Development build (v6.5.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DiagnosticReportRecord

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportRecord Version: 6.5.0
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

Usages:

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

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 ?!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 preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 1..1 string Representation defined by the system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... title Σ 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... section SC 1..1 BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 1..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... Slices for entry SC 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient.
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DiagnosticReport
..... entry:DocumentReference C 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
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|4.0.1
From the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
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()

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 S 1..1 code preliminary | final | amended | entered-in-error
... type S 1..1 CodeableConcept Kind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
..... display 1..1 string Representation defined by the system
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... author S 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... section S 1..1 BackboneElement Composition is broken into sections
.... code
..... coding S 0..* Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... Slices for entry S 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient.
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
...... type 1..1 uri Type the reference refers to (e.g. "Patient")
Fixed Value: DiagnosticReport
..... entry:DocumentReference 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
...... type 1..1 uri Type 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 & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 1..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... 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 ΣC 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) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... 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 ΣC 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
... title Σ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... 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
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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
.... code Σ 0..* CodeableConcept Code(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 Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..1 BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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
.... title 0..1 string Label for section (e.g. for ToC)
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... Slices for entry SC 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on 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 ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DiagnosticReport
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... entry:DocumentReference C 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... 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 ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DocumentReference
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages|4.0.1
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
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|4.0.1
From the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
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|4.0.1
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|4.0.1
From the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 ?!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 preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 1..1 string Representation defined by the system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... title Σ 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... section SC 1..1 BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 1..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... Slices for entry SC 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient.
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DiagnosticReport
..... entry:DocumentReference C 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
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|4.0.1
From the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
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 & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 S 1..1 code preliminary | final | amended | entered-in-error
... type S 1..1 CodeableConcept Kind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
..... display 1..1 string Representation defined by the system
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... author S 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... section S 1..1 BackboneElement Composition is broken into sections
.... code
..... coding S 0..* Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... Slices for entry S 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient.
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
...... type 1..1 uri Type the reference refers to (e.g. "Patient")
Fixed Value: DiagnosticReport
..... entry:DocumentReference 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
...... type 1..1 uri Type 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

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A 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 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (SNOMED CT if possible)
Binding: Diagnostic Report Type (preferred)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 1..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... 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 ΣC 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) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) Who and/or what authored the composition
.... 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 ΣC 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
... title Σ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... 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
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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
.... code Σ 0..* CodeableConcept Code(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 Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..1 BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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
.... title 0..1 string Label for section (e.g. for ToC)
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... Slices for entry SC 1..2 Reference(Resource) A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:DiagnosticReport C 0..1 Reference(DiagnosticReportLab | DiagnosticReportImaging) The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on 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 ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DiagnosticReport
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... entry:DocumentReference C 0..1 Reference(DocumentReference) The section records documents, such as PDFs or images, relevant to the DiagnosticReport
...... 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 ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 1..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).
Fixed Value: DocumentReference
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages|4.0.1
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
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|4.0.1
From the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
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|4.0.1
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|4.0.1
From the FHIR Standard
Composition.section.entry:DiagnosticReport.typeextensibleFixed Value: DiagnosticReport
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.entry:DocumentReference.typeextensibleFixed Value: DocumentReference
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
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()

 

Other representations of profile: CSV, Excel, Schematron