MedCom HomeCareObservation
1.0.0 - release
MedCom HomeCareObservation
1.0.0 - release
This page is part of the The DK MedCom HomeCareObservation (v1.0.0: Release) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://medcomfhir.dk/ig/homecareobservation/StructureDefinition/medcom-homecare-diagnosticreport | Version: 1.0.0 | |||
| Active as of 2023-10-31 | Computable Name: MedComHomeCareDiagnosticReport | |||
This resource is intenden to be used in relation with a HomeCareObservation message
The MedComHomeCareDiagnosticReport profile contains references to all observation results performed and produced by the municipal acute care team, with the purpose of sending the HomeCareObservation to citizens genereal practitioner. The MedComHomeCareDiagnosticReport is sent as a HomeCareObservation message.
In a DiagnosticRepport resource, it is required to specify the status of the repport. When all results from performeded observations by the acute care team are typed ind then the HomeCareDiagnosticRepport.status shall be #final.
In the MedComHomeCareDiagnosticReport it is possible to send comments regarding the performed and produced observation results by the municipal acute care team. There are two types of comments that can be send; analysis comments about individual analysis and results, and a clinical comment (overall nursing assessment) about the entire report.
Analysis comment (Danish: Analysekommentar) is a comment that the user can choose to add, if relevant, to an individual observation result. The element Observation.note in HomeCareObservation profile shall be used when adding a analysis comment about the observation. The analysis comment shall not exceed 1 MB (1024 x 1024 characters) in size.
The clinical comment (Danish: Klinisk kommentar) is a comment to the etntire report. This comment shall contain information that is necessary to provide an overall assessment of the citizen in the acute situation. It is recommended that the municipal acute careteam send the relevant clinical observations (nursing assessment) that are necessary in order to understand and interpret the citizens overall results and health status. When adding a clinical comment the element DiagnosticReport.conclusion shall be used. The clinical comment shall not exceed 1 MB (1024 x 1024 characters) in size.
In the MedComHomeCareDiagnosticReport it is required to describe the performer of the MedComHomeCareDiagnosticReport. The performer is organization that is responsible for creating the HomeCareDiagnosticRepport e.g acute care team . The performer shall be described using a signature and a producer-ID.
It is required to send the siganure of the MedComHomeCareDiagnosticReport performer. The signature consist of:
The producer-ID consist of a three letter code and a SOR-ID for the municiplity where the acute care team is owned by. The three letter code is exhibited by MedCom and is an abbreviation for the producer (e.g. unit or organization) that is responsible for the observations results. The municipal acute care team is responsible for performig and producing the observations results in the MedCom HomeCareObservation. Therefore the code for the municiapl acute careteam is “KAF”. The three letter code is exibited in code system on the terminology IG. Click here to see the code system.
If a patient not allow to share the observation results with other than the general practitioner a securety 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.
In MedComHomeCareDiagnosticReport it is allowed to include attachments. When including an attachment to a HomeCareDiagnosticReport then the element DiagnosticReport.media.link 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
The attached file shall be base64ed and added to MedComCoreMedia.content.data element. If the attached file are sent, it is a requirement that the ID and title of the attached file shall be sent. The ID of the attachment shall be expressed using Media.identifier element. The Media.content.titel element shall be used to express the titel of the attachment.
Furthermore, MedCom recommended that the name of the author, as well as the time of creation, of the attached file be signed and sent with it. To express the author of the attachemn the Media.operator shal be used. The time of creation, of the attached file shall be expressed using Media.content.creation element
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from MedComCoreDiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | MedComCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  meta | ||||
  security | S | 0..1 | Coding | Security Labels applied to this resource Required Pattern: At least the following |
   system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |
| status | ||||
| value | 0..1 | string | Primitive value for code Required Pattern: final | |
 Slices for performer | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() | |
  performer:ProducerOrganization | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer | |
 performer:PractitionerRole | C | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. |
 result | 0..* | Reference(MedComHomeCareObservation) {b} | Observations | |
| conclusion | 0..1 | string | A comment relevant for all observations in the report and necessary to interpret and understand the results (Danish:Klinisk kommentar). | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | MedComCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| security | SΣ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |
 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) |
| value | 0..1 | string | Primitive value for code Required Pattern: final | |
| 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 |
| Slices for performer | SΣ | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() |
| performer:ProducerOrganization | SΣ | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer |
| performer:PractitionerRole | SΣC | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. |
| result | S | 0..* | Reference(MedComHomeCareObservation) {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 and necessary to interpret and understand the results (Danish:Klinisk kommentar). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.meta.security | extensible | Pattern: R("Restricted") |
| DiagnosticReport.status | required | http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValueset |
| 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() | |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | MedComCoreDiagnosticReport | 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
 extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId | Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
| source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security | SΣ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| 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) | ||||
| id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| value | 0..1 | string | Primitive value for code Required Pattern: final | |||||
| 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 | ||||
| Slices for performer | SΣ | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() | ||||
| performer:ProducerOrganization | SΣ | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer | ||||
| performer:PractitionerRole | SΣC | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. | ||||
| 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(MedComHomeCareObservation) {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 and necessary to interpret and understand the results (Danish:Klinisk kommentar). | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| DiagnosticReport.meta.security | extensible | Pattern: R("Restricted") | ||||
| DiagnosticReport.meta.tag | example | CommonTags | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValueset | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| 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() | |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
This structure is derived from MedComCoreDiagnosticReport
Summary
Mandatory: 2 elements
Must-Support: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from MedComCoreDiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | MedComCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| meta | ||||
| security | S | 0..1 | Coding | Security Labels applied to this resource Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |
| status | ||||
| value | 0..1 | string | Primitive value for code Required Pattern: final | |
| Slices for performer | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() | |
| performer:ProducerOrganization | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer | |
| performer:PractitionerRole | C | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. |
| result | 0..* | Reference(MedComHomeCareObservation) {b} | Observations | |
| conclusion | 0..1 | string | A comment relevant for all observations in the report and necessary to interpret and understand the results (Danish:Klinisk kommentar). | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | MedComCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| security | SΣ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. Required Pattern: At least the following |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |
| 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) |
| value | 0..1 | string | Primitive value for code Required Pattern: final | |
| 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 |
| Slices for performer | SΣ | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() |
| performer:ProducerOrganization | SΣ | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer |
| performer:PractitionerRole | SΣC | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. |
| result | S | 0..* | Reference(MedComHomeCareObservation) {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 and necessary to interpret and understand the results (Danish:Klinisk kommentar). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.meta.security | extensible | Pattern: R("Restricted") |
| DiagnosticReport.status | required | http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status |
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValueset |
| 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() | |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | MedComCoreDiagnosticReport | 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId | Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
| source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security | SΣ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-Confidentiality | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Restricted | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| 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) | ||||
| id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| value | 0..1 | string | Primitive value for code Required Pattern: final | |||||
| 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 | ||||
| Slices for performer | SΣ | 2..2 | Reference(MedComCoreProducerOrganization | MedComCorePractitionerRole) | Performer of the observations. Shall include a name, practitioner role, relevant telephone of the producer. Slice: Unordered, Closed by profile:resolve() | ||||
| performer:ProducerOrganization | SΣ | 1..1 | Reference(MedComCoreProducerOrganization) {b} | Producer organization of the observations. Shall include a producer-ID (Danish: Producent-ID) of the producer | ||||
| performer:PractitionerRole | SΣC | 1..1 | Reference(MedComCorePractitionerRole) {b} | Responsible Diagnostic Service medcom-homecareReport-1: There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. medcom-homecareReport-2: There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. medcom-homecareReport-3: There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. | ||||
| 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(MedComHomeCareObservation) {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 and necessary to interpret and understand the results (Danish:Klinisk kommentar). | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| DiagnosticReport.meta.security | extensible | Pattern: R("Restricted") | ||||
| DiagnosticReport.meta.tag | example | CommonTags | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | http://medcomfhir.dk/ig/terminology/ValueSet/medcom-corediagnosticrepport-status | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | required | MedComDiagnosticReportCodesValueset | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| 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() | |
| medcom-homecareReport-1 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a practitioner role when using a PractitionerRole as author in a HomeCare Report. : reference.resolve().code.coding.code.exists() | |
| medcom-homecareReport-2 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a name of the healtcare worker that performed the observations, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().name.exists() | |
| medcom-homecareReport-3 | error | DiagnosticReport.performer:PractitionerRole | There shall exist a telecom to the organization form the healthcare worker is part of, as author in a HomeCare Report. : reference.resolve().practitioner.resolve().telecom.where(system = 'phone').exists() |
This structure is derived from MedComCoreDiagnosticReport
Summary
Mandatory: 2 elements
Must-Support: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron