ReteLabDiagnosticReportRisultatiDisponibili
Descrizione
Il profilo ReteLabDiagnosticReportRisultatiDisponibili è stato strutturato a partire dalla risorsa generica FHIR DiagnosticReport utilizzata per descrivere i risultati disponibili degli esami analizzati.
Di seguito è presentato il contenuto del profilo in diversi formati. La corrispondente definizione è consultabile al seguente link: ReteLabDiagnosticReportRisultatiDisponibili.
Snapshot View
| ReteLabDiagnosticReportRisultatiDisponibili (DiagnosticReport) | C | DiagnosticReport | Element idDiagnosticReportShort description Profilo che contiene informazioni relative ai risultati disponibili prima che venga redatto il referto Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. Questo profilo può essere presente nei seguenti flussi: "Notifica risultati disponibili da LS a LR"
| |||
| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
| ||
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
| ||
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
| |||
| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
| |||
| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| identifier | Σ | 0..* | Identifier | Element idDiagnosticReport.identifierShort description Identificativo univoco dell'insieme dei risultati Alternate namesReportID, Filler ID, Placer ID DefinitionIdentificativo univoco dell'insieme dei risultati presenti nel messaggio. Dev'essere assegnato dal Laboratorio servente. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
| ||
| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
| ||
| system | Σ | 0..1 | uriAuto Value | Element idDiagnosticReport.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.siss.regione.lombardia.it/sid/codiceIdentificativoRisultatiExamples General http://www.acme.com/identifiers/patientMappings
| ||
| value | Σ | 0..1 | string | Element idDiagnosticReport.identifier.valueShort description Identificativo univoco dell'insieme dei risultati DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. Come da specifiche HL7: OBR-21
General 123456Mappings
| ||
| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
| ||
| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
| ||
| basedOn | 1..* | Reference(ReteLabServiceRequestRichiestaEsamiLab) | Element idDiagnosticReport.basedOnShort description Richiesta di esame di laboratorio di cui si riportano i risultati Alternate namesRequest DefinitionReference al profilo ReteLabServiceRequestRichiestaEsamiLab This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(ReteLabServiceRequestRichiestaEsamiLab) Constraints
| |||
| status | Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Stato del DiagnosticReport DefinitionPuò assumere i seguenti valori:
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Valutato rispetto i campi HL7 secondo specifiche regionali: ORC-5, OBR-25, OBX-11 The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
| ||
| category | Σ | 0..* | CodeableConceptAuto Value | Element idDiagnosticReport.categoryShort description Referti di Laboratorio Alternate namesDepartment, Sub-department, Service, Discipline DefinitionValore fisso su LAB --> Laboratorio Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) Constraints
{
"coding": [
{
"system": "http://hl7.org/fhir/Codesystem/diagnostic-service-sections",
"code": "LAB",
"display": "Laboratorio"
}
]
}Mappings
| ||
| code | Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Tipologia risultati disponibili Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
| ||
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
| ||
| code | Σ | 0..1 | codeBindingAuto Value | Element idDiagnosticReport.code.coding.codeShort description Codice tipologia risultati disponibili DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. ValueSet relativo alla tipologia del report
01Mappings
| ||
| display | Σ | 0..1 | stringAuto Value | Element idDiagnosticReport.code.coding.displayShort description Descrizione tipologia risultati disponibili DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Risultati DisponibiliMappings
| ||
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
| ||
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
| ||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | There are no (further) constraints on this element Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context. Reference(Patient | Group | Device | Location) Constraints
| ||
| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
| ||
| effective[x] | Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
| |||
| effectiveDateTime | dateTime | There are no (further) constraints on this element Data type | ||||
| effectivePeriod | Period | There are no (further) constraints on this element Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
| ||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
| ||
| resultsInterpreter | Σ | 0..* | Reference(ReteLabPractitionerRoleMedico) | Element idDiagnosticReport.resultsInterpreterShort description Dati del medico responsabile dei risultati Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Corrispondente campo HL7 secondo specifiche regionali: OBX-16 Reference(ReteLabPractitionerRoleMedico) Constraints
| ||
| specimen | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
| |||
| result | 1..* | Reference(ReteLabObservationRisultati) | Element idDiagnosticReport.resultShort description Risultati degli esami di laboratorio richiesti e presenti nelle ServiceRequest Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReference al profilo ReteLabObservationRisultati Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Segmento HL7: OBX Reference(ReteLabObservationRisultati) Constraints
| |||
| imagingStudy | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
| |||
| media | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDiagnosticReport.mediaShort description Key images associated with this report Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
| |||
| link | Σ | 1..1 | Reference(Media) | There are no (further) constraints on this element Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source.
| ||
| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
| |||
| conclusionCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
| |||
| presentedForm | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
|
Differential View
| ReteLabDiagnosticReportRisultatiDisponibili (DiagnosticReport) | C | DiagnosticReport | Element idDiagnosticReportShort description Profilo che contiene informazioni relative ai risultati disponibili prima che venga redatto il referto Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. Questo profilo può essere presente nei seguenti flussi: "Notifica risultati disponibili da LS a LR"
| |||
| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
| ||
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
| ||
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
| |||
| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
| |||
| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| identifier | Σ | 0..* | Identifier | Element idDiagnosticReport.identifierShort description Identificativo univoco dell'insieme dei risultati Alternate namesReportID, Filler ID, Placer ID DefinitionIdentificativo univoco dell'insieme dei risultati presenti nel messaggio. Dev'essere assegnato dal Laboratorio servente. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
| ||
| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
| ||
| system | Σ | 0..1 | uriAuto Value | Element idDiagnosticReport.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.siss.regione.lombardia.it/sid/codiceIdentificativoRisultatiExamples General http://www.acme.com/identifiers/patientMappings
| ||
| value | Σ | 0..1 | string | Element idDiagnosticReport.identifier.valueShort description Identificativo univoco dell'insieme dei risultati DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. Come da specifiche HL7: OBR-21
General 123456Mappings
| ||
| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
| ||
| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
| ||
| basedOn | 1..* | Reference(ReteLabServiceRequestRichiestaEsamiLab) | Element idDiagnosticReport.basedOnShort description Richiesta di esame di laboratorio di cui si riportano i risultati Alternate namesRequest DefinitionReference al profilo ReteLabServiceRequestRichiestaEsamiLab This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(ReteLabServiceRequestRichiestaEsamiLab) Constraints
| |||
| status | Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Stato del DiagnosticReport DefinitionPuò assumere i seguenti valori:
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Valutato rispetto i campi HL7 secondo specifiche regionali: ORC-5, OBR-25, OBX-11 The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
| ||
| category | Σ | 0..* | CodeableConceptAuto Value | Element idDiagnosticReport.categoryShort description Referti di Laboratorio Alternate namesDepartment, Sub-department, Service, Discipline DefinitionValore fisso su LAB --> Laboratorio Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) Constraints
{
"coding": [
{
"system": "http://hl7.org/fhir/Codesystem/diagnostic-service-sections",
"code": "LAB",
"display": "Laboratorio"
}
]
}Mappings
| ||
| code | Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Tipologia risultati disponibili Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
| ||
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
| ||
| code | Σ | 0..1 | codeBindingAuto Value | Element idDiagnosticReport.code.coding.codeShort description Codice tipologia risultati disponibili DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. ValueSet relativo alla tipologia del report
01Mappings
| ||
| display | Σ | 0..1 | stringAuto Value | Element idDiagnosticReport.code.coding.displayShort description Descrizione tipologia risultati disponibili DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Risultati DisponibiliMappings
| ||
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
| ||
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
| ||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | There are no (further) constraints on this element Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context. Reference(Patient | Group | Device | Location) Constraints
| ||
| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
| ||
| effective[x] | Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
| |||
| effectiveDateTime | dateTime | There are no (further) constraints on this element Data type | ||||
| effectivePeriod | Period | There are no (further) constraints on this element Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
| ||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
| ||
| resultsInterpreter | Σ | 0..* | Reference(ReteLabPractitionerRoleMedico) | Element idDiagnosticReport.resultsInterpreterShort description Dati del medico responsabile dei risultati Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Corrispondente campo HL7 secondo specifiche regionali: OBX-16 Reference(ReteLabPractitionerRoleMedico) Constraints
| ||
| specimen | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
| |||
| result | 1..* | Reference(ReteLabObservationRisultati) | Element idDiagnosticReport.resultShort description Risultati degli esami di laboratorio richiesti e presenti nelle ServiceRequest Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReference al profilo ReteLabObservationRisultati Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Segmento HL7: OBX Reference(ReteLabObservationRisultati) Constraints
| |||
| imagingStudy | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
| |||
| media | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDiagnosticReport.mediaShort description Key images associated with this report Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
| |||
| link | Σ | 1..1 | Reference(Media) | There are no (further) constraints on this element Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source.
| ||
| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
| |||
| conclusionCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
| |||
| presentedForm | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
|
Hybrid View
| ReteLabDiagnosticReportRisultatiDisponibili (DiagnosticReport) | C | DiagnosticReport | Element idDiagnosticReportShort description Profilo che contiene informazioni relative ai risultati disponibili prima che venga redatto il referto Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. Questo profilo può essere presente nei seguenti flussi: "Notifica risultati disponibili da LS a LR"
| |||
| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
| ||
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
| ||
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
| |||
| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
| |||
| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| identifier | Σ | 0..* | Identifier | Element idDiagnosticReport.identifierShort description Identificativo univoco dell'insieme dei risultati Alternate namesReportID, Filler ID, Placer ID DefinitionIdentificativo univoco dell'insieme dei risultati presenti nel messaggio. Dev'essere assegnato dal Laboratorio servente. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Usually assigned by the Information System of the diagnostic service provider (filler id).
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
| ||
| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints
| ||
| system | Σ | 0..1 | uriAuto Value | Element idDiagnosticReport.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.siss.regione.lombardia.it/sid/codiceIdentificativoRisultatiExamples General http://www.acme.com/identifiers/patientMappings
| ||
| value | Σ | 0..1 | string | Element idDiagnosticReport.identifier.valueShort description Identificativo univoco dell'insieme dei risultati DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. Come da specifiche HL7: OBR-21
General 123456Mappings
| ||
| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
| ||
| assigner | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
| ||
| basedOn | 1..* | Reference(ReteLabServiceRequestRichiestaEsamiLab) | Element idDiagnosticReport.basedOnShort description Richiesta di esame di laboratorio di cui si riportano i risultati Alternate namesRequest DefinitionReference al profilo ReteLabServiceRequestRichiestaEsamiLab This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(ReteLabServiceRequestRichiestaEsamiLab) Constraints
| |||
| status | Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Stato del DiagnosticReport DefinitionPuò assumere i seguenti valori:
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Valutato rispetto i campi HL7 secondo specifiche regionali: ORC-5, OBR-25, OBX-11 The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
| ||
| category | Σ | 0..* | CodeableConceptAuto Value | Element idDiagnosticReport.categoryShort description Referti di Laboratorio Alternate namesDepartment, Sub-department, Service, Discipline DefinitionValore fisso su LAB --> Laboratorio Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) Constraints
{
"coding": [
{
"system": "http://hl7.org/fhir/Codesystem/diagnostic-service-sections",
"code": "LAB",
"display": "Laboratorio"
}
]
}Mappings
| ||
| code | Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Tipologia risultati disponibili Alternate namesType DefinitionA code or name that describes this diagnostic report. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
| ||
| system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
| ||
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
| ||
| code | Σ | 0..1 | codeBindingAuto Value | Element idDiagnosticReport.code.coding.codeShort description Codice tipologia risultati disponibili DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. ValueSet relativo alla tipologia del report
01Mappings
| ||
| display | Σ | 0..1 | stringAuto Value | Element idDiagnosticReport.code.coding.displayShort description Descrizione tipologia risultati disponibili DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Risultati DisponibiliMappings
| ||
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
| ||
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
| ||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | There are no (further) constraints on this element Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context. Reference(Patient | Group | Device | Location) Constraints
| ||
| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
| ||
| effective[x] | Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
| |||
| effectiveDateTime | dateTime | There are no (further) constraints on this element Data type | ||||
| effectivePeriod | Period | There are no (further) constraints on this element Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
| ||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints
| ||
| resultsInterpreter | Σ | 0..* | Reference(ReteLabPractitionerRoleMedico) | Element idDiagnosticReport.resultsInterpreterShort description Dati del medico responsabile dei risultati Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Corrispondente campo HL7 secondo specifiche regionali: OBX-16 Reference(ReteLabPractitionerRoleMedico) Constraints
| ||
| specimen | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
| |||
| result | 1..* | Reference(ReteLabObservationRisultati) | Element idDiagnosticReport.resultShort description Risultati degli esami di laboratorio richiesti e presenti nelle ServiceRequest Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReference al profilo ReteLabObservationRisultati Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Segmento HL7: OBX Reference(ReteLabObservationRisultati) Constraints
| |||
| imagingStudy | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.imagingStudyShort description Reference to full details of imaging associated with the diagnostic report DefinitionOne or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
| |||
| media | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDiagnosticReport.mediaShort description Key images associated with this report Alternate namesDICOM, Slides, Scans DefinitionA list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images in the report as part of their service.
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
| ||
| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. The provider of the report should make a comment about each image included in the report. The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
| |||
| link | Σ | 1..1 | Reference(Media) | There are no (further) constraints on this element Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source.
| ||
| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data.
| |||
| conclusionCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDiagnosticReport.conclusionCodeShort description Codes for the clinical conclusion of test results DefinitionOne or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints
| |||
| presentedForm | 0..* | Attachment | There are no (further) constraints on this element Element idDiagnosticReport.presentedFormShort description Entire report as issued DefinitionRich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context.
|
Table View
| DiagnosticReport | .. | |
| DiagnosticReport.identifier | .. | |
| DiagnosticReport.identifier.system | .. | |
| DiagnosticReport.identifier.value | .. | |
| DiagnosticReport.basedOn | Reference(ReteLabServiceRequestRichiestaEsamiLab) | 1.. |
| DiagnosticReport.status | .. | |
| DiagnosticReport.category | .. | |
| DiagnosticReport.code | .. | |
| DiagnosticReport.code.coding | .. | |
| DiagnosticReport.code.coding.code | .. | |
| DiagnosticReport.code.coding.display | .. | |
| DiagnosticReport.resultsInterpreter | Reference(ReteLabPractitionerRoleMedico) | .. |
| DiagnosticReport.result | Reference(ReteLabObservationRisultati) | 1.. |
XML View
JSON View
ValueSet
Nella seguente tabella sono elencati i value set relativi al profilo ReteLabDiagnosticReportRisultatiDisponibili:
| Nome | Descrizione | Riferimento al dettaglio della codifica |
|---|---|---|
| Tipologia report | Codice della tipologia dei risultati disponibili | La codifica è definita dal ValueSet Tipologia Report |