Note: This profile is developed to be part of a production trial of the communication between the general practitioner and municipal acute care team.

Scope and usage

This profile is intended to be uses in MedCom HomeCareObservation and MedCom’s Laboratory standards.

Attachments

In MedComCoreDiagnosticReport it is allowed to include attachments. When sending an attachment diagnosticReport.media shall be used. The DiagnosticReport.media.link reference to MedComCoreMedia resource where the atachment shall be added. It is up to the user to assess when it is relevant to send an attachment. Only an attachment of the permitted formats must be included. Click here to see the permitted formats of an attachment

Use of security labet on patient consent

If a patient gives a negative consent to sharing the observation results with other than the general practitioner a security labe shall be used. This mean that the meta.security.code shall be R, and in the user interface, it shall be clearly stated that consent has been refused.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
status	S	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
code	S	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	S	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
issued	S	1..1	instant	DateTime this version was made
performer	S	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
media	S	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
link	S	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	SΣ	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
issued	SΣ	1..1	instant	DateTime this version was made
performer	SΣ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
media	SΣ	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
link	SΣ	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier for report
basedOn		0..*	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
status	?!SΣ	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
category	Σ	0..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	SΣ	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	SΣ	1..1	instant	DateTime this version was made
performer	SΣ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	SΣ	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
comment		0..1	string	Comment about the image (e.g. explanation)
link	SΣ	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
conclusionCode		0..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.category	example	DiagnosticServiceSectionCodes
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
status	S	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
code	S	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	S	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
issued	S	1..1	instant	DateTime this version was made
performer	S	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
media	S	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
link	S	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	SΣ	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
issued	SΣ	1..1	instant	DateTime this version was made
performer	SΣ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
media	SΣ	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
link	SΣ	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier for report
basedOn		0..*	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
status	?!SΣ	1..1	code	​registered | partial | preliminary | final | corrected | cancelled | entered-in-error Binding: http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status (required)
category	Σ	0..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: MedComDiagnosticReportCodesValueset (required)
subject	SΣ	1..1	Reference(MedComCorePatient) {b}	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	SΣ	1..1	instant	DateTime this version was made
performer	SΣ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result	S	0..*	Reference(MedComCoreObservation) {b}	Observations
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	SΣ	0..*	BackboneElement	Attachments that are relevant for assessment of the patient's condition.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
comment		0..1	string	Comment about the image (e.g. explanation)
link	SΣ	1..1	Reference(MedComMedia)	Reference to the image source
conclusion	S	0..1	string	A comment relevant for all observations in the report.
conclusionCode		0..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DiagnosticReport.status	required	​http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status
DiagnosticReport.category	example	DiagnosticServiceSectionCodes
DiagnosticReport.code	required	MedComDiagnosticReportCodesValueset
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DiagnosticReport

Summary

Mandatory: 2 elements
Must-Support: 9 elements

Structures

This structure refers to these other structures:

• MedComCorePatient (http://medcomfhir.dk/ig/core/StructureDefinition/medcom-core-patient)
• MedComCoreObservation (http://medcomfhir.dk/ig/core/StructureDefinition/medcom-core-observation)
• MedComMedia (http://medcomfhir.dk/ig/core/StructureDefinition/medcom-core-media)