Integrated Reporting Applications
1.0.0 - Trial-Implementation
Integrated Reporting Applications
1.0.0 - Trial-Implementation
This page is part of the Integrated Reporting Applications (v1.0.0: Publication) based on FHIR v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: https://profiles.ihe.net/RAD/IRA/StructureDefinition/diagnosticreportcontext | Version: 1.0.0 | |||
| Active as of 2023-10-03 | Computable Name: DiagnosticReportContext | |||
IHE IRA DiagnosticReport-open report context
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  status | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Required Pattern: unknown | |
 subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
 study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| contained | 0..* | Resource | Contained, inline Resources | |
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown |
 code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports |
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
| study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.status | required | Pattern: unknown |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown | ||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports | ||||
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
 effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
 effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result | C | 0..* | Reference(Observation) | Observations | ||||
| note | 0..* | Annotation | Comments about the diagnostic report | |||||
| study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |||||
| supportingInfo | 0..* | BackboneElement | Additional information supporting the diagnostic report | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report. | |||||
| reference | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference | |||||
| media | Σ | 0..* | BackboneElement | Key images or data associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image or data (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data source | ||||
| composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure | ||||
| conclusion | 0..1 | markdown | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.language | required | AllLanguages |
| DiagnosticReport.status | required | Pattern: unknown |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
| DiagnosticReport.supportingInfo.type | example | Hl7VSVSObservationType |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
This structure is derived from DiagnosticReport
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| status | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Required Pattern: unknown | |
| subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
| study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| contained | 0..* | Resource | Contained, inline Resources | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown |
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports |
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
| study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.status | required | Pattern: unknown |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Required Pattern: unknown | ||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports | ||||
| subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result | C | 0..* | Reference(Observation) | Observations | ||||
| note | 0..* | Annotation | Comments about the diagnostic report | |||||
| study | 1..1 | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report | |||||
| supportingInfo | 0..* | BackboneElement | Additional information supporting the diagnostic report | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Supporting information role code Binding: hl7VS-VS-observationType (example): The code value for the role of the supporting information in the diagnostic report. | |||||
| reference | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference | |||||
| media | Σ | 0..* | BackboneElement | Key images or data associated with this report | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment | 0..1 | string | Comment about the image or data (e.g. explanation) | |||||
| link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data source | ||||
| composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure | ||||
| conclusion | 0..1 | markdown | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.language | required | AllLanguages |
| DiagnosticReport.status | required | Pattern: unknown |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC) |
| DiagnosticReport.supportingInfo.type | example | Hl7VSVSObservationType |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
This structure is derived from DiagnosticReport
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ IHE Radiology Technical Committee. Package ihe.rad.ira#1.0.0 based on FHIR 5.0.0. Generated 2023-10-03
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