RetinaIntegration
0.5.0 - ci-build
RetinaIntegration - Local Development build (v0.5.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Draft as of 2025-12-08 |
Definitions for the retina-diagnostic-report resource profile.
Guidance on how to interpret the contents of this table can be foundhere
| 0. DiagnosticReport | |
| Definition | The 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. |
| Short | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
| Comments | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. |
| Control | 0..* |
| Is Modifier | false |
| Summary | false |
| Alternate Names | Report, Test, Result, Results, Labs, Laboratory |
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
| 2. DiagnosticReport.implicitRules | |
| Definition | A 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. |
| Short | A set of rules under which this content was created |
| Comments | 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. |
| Control | 0..01 |
| Type | uri |
| Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 4. DiagnosticReport.extension | |
| Definition | An Extension May 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. |
| Short | ExtensionAdditional content defined by implementations |
| Comments | 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. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on DiagnosticReport.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 6. DiagnosticReport.extension:daysUntilNextExamination | |
| Slice Name | daysUntilNextExamination |
| Definition | Number of days until next examination. |
| Short | Days Until Next Examination |
| Control | 0..1 This element is affected by the following invariants: ele-1 |
| Type | Extension(Days Until Next Examination) (Extension Type: integer) |
| Is Modifier | false |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists())ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 8. DiagnosticReport.extension:cautions | |
| Slice Name | cautions |
| Definition | Special considerations or cautions for grading this examination (5000-series). |
| Short | Cautions |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Type | Extension(Cautions) (Extension Type: CodeableConcept) |
| Is Modifier | false |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists())ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 10. DiagnosticReport.extension:previousExaminationConclusion | |
| Slice Name | previousExaminationConclusion |
| Definition | The conclusion from the previous examination (1000 series). If this is the first examination, this extension is not present. |
| Short | Previous Examination Conclusion |
| Control | 0..1 This element is affected by the following invariants: ele-1 |
| Type | Extension(Previous Examination Conclusion) (Extension Type: Coding) |
| Is Modifier | false |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists())ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 12. DiagnosticReport.modifierExtension | |
| Definition | An Extension May 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). |
| Short | ExtensionExtensions that cannot be ignored |
| Comments | 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. |
| Control | 0..0* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
| Summary | false |
| Requirements | 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. |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 14. DiagnosticReport.identifier | |
| Definition | Identifiers assigned to this report by the performer or other systems. |
| Short | Business identifier for report |
| Comments | Usually assigned by the Information System of the diagnostic service provider (filler id). |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 10..* |
| Type | Identifier |
| Is Modifier | false |
| Summary | true |
| Requirements | 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. |
| Alternate Names | ReportID, Filler ID, Placer ID |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on DiagnosticReport.identifier. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 16. DiagnosticReport.identifier:retinaExaminationId | |
| Slice Name | retinaExaminationId |
| Definition | Identifies the retina examination in RetinaIntegration. Value must be a valid GUID in format: xxxxxxxx-xxxx-xxxx-xxxx-xxxxxxxxxxxx Identifiers assigned to this report by the performer or other systems. |
| Short | Retina Examination Identifier (GUID)Business identifier for report |
| Comments | Usually assigned by the Information System of the diagnostic service provider (filler id). |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 10..1* |
| Type | Identifier |
| Is Modifier | false |
| Summary | true |
| Requirements | 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. |
| Alternate Names | ReportID, Filler ID, Placer ID |
| Example | UUID Identifier: { "system" : "http://dips.no/fhir/RetinaIntegration/examination-id", "value" : "550e8400-e29b-41d4-a716-446655440000" } |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 18. DiagnosticReport.identifier:retinaExaminationId.use | |
| Definition | The purpose of this identifier. |
| Short | usual | official | temp | secondary | old (If known) |
| Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
| Control | 0..01 |
| Binding | The codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)Identifies the purpose for this identifier, if known . |
| Type | code |
| Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 20. DiagnosticReport.identifier:retinaExaminationId.system | |
| Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
| Short | The namespace for the identifier value |
| Comments | Identifier.system is always case sensitive. |
| Control | 10..1 |
| Type | uri |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Requirements | 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. |
| Pattern Value | http://dips.no/fhir/RetinaIntegration/examination-id |
| Example | General: http://www.acme.com/identifiers/patient |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 22. DiagnosticReport.identifier:retinaExaminationId.value | |
| Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. |
| Short | Unique identifier for the examination (GUID)The value that is unique |
| Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. |
| Control | 10..1 |
| Type | string |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Example | General: 123456 |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 24. DiagnosticReport.status | |
| Definition | Use 'preliminary' when the examination is created and awaiting AI/manual grading. Use 'final' when grading is complete. The status of the diagnostic report. |
| Short | Status of the diagnostic report: registered | partial | finalregistered | partial | preliminary | final + |
| Control | 1..1 |
| Binding | The codes SHALL be taken from DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1)The status of the diagnostic report. |
| Type | code |
| Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Requirements | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 26. DiagnosticReport.code | |
| Definition | The type(s) of retinal imaging procedure(s) the photographer has indicated shall be performed. A code or name that describes this diagnostic report. |
| Short | Retina imaging procedure(s) performed: fundus photography and/or OCTName/Code for this diagnostic report |
| Control | 1..1 |
| Binding | The codes SHALL be taken from The codes SHOULD be taken from Retina Imaging Procedureshttp://hl7.org/fhir/ValueSet/report-codes|4.0.1 (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-imaging-procedure-vs) |
| Type | CodeableConcept |
| Is Modifier | false |
| Summary | true |
| Alternate Names | Type |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 28. DiagnosticReport.subject | |
| Definition | A reference to the patient. The patient's identifier MUST be one of the official Norwegian patient identifier systems: Fødselsnummer (urn:oid:2.16.578.1.12.4.1.4.1), D-nummer (urn:oid:2.16.578.1.12.4.1.4.2), or Felles hjelpenummer (urn:oid:2.16.578.1.12.4.1.4.3). The 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. |
| Short | Reference to the patientThe subject of the report - usually, but not always, the patient |
| Control | 0..1 |
| Type | Reference(Patient, Patient, Group, Device, Location) |
| Is Modifier | false |
| Summary | true |
| Requirements | SHALL know the subject context. |
| Alternate Names | Patient |
| Example | Patient with Fødselsnummer: {
"reference" : "Patient/cdp1000807",
"identifier" : {
"system" : "urn:oid:2.16.578.1.12.4.1.4.1",
"value" : "15076500565"
}
} Patient with D-nummer: { "reference" : "Patient/cdp1004445", "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.2", "value" : "41018512345" } } Patient with Felles Hjelpenummer: { "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.3", "value" : "11223344556" } } |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 30. DiagnosticReport.performer | |
| Definition | The diagnostic service that is responsible for issuing the report. |
| Short | Responsible Diagnostic Service |
| Comments | 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. |
| Control | 0..0* |
| Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam) |
| Is Modifier | false |
| Summary | true |
| Requirements | 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. |
| Alternate Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 32. DiagnosticReport.resultsInterpreter | |
| Definition | The practitioner or organization that is responsible for the report's conclusions and interpretations. |
| Short | Primary result interpreter |
| Comments | Might not be the same entity that takes responsibility for the clinical report. |
| Control | 0..0* |
| Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam) |
| Is Modifier | false |
| Summary | true |
| Requirements | 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. |
| Alternate Names | Analyzed by, Reported by |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 34. DiagnosticReport.result | |
| Definition | Observations that are part of this diagnostic report. |
| Short | Observations |
| Comments | Observations can contain observations. |
| Control | 0..* |
| Type | Reference(Observation) |
| Is Modifier | false |
| Summary | false |
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. |
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on DiagnosticReport.result. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 36. DiagnosticReport.result:hbA1cObservation | |
| Slice Name | hbA1cObservation |
| Definition | Observations that are part of this diagnostic report. |
| Short | Optional HbA1c Laboratory ResultObservations |
| Comments | Observations can contain observations. |
| Control | 0..1* |
| Type | Reference(Retina HbA1c Observation, Observation) |
| Is Modifier | false |
| Summary | false |
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. |
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 38. DiagnosticReport.result:dmeFinding | |
| Slice Name | dmeFinding |
| Definition | Observations that are part of this diagnostic report. |
| Short | Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.Observations |
| Comments | Observations can contain observations. |
| Control | 0..2* |
| Type | Reference(Retina Diabetic Macular Edema Finding, Observation) |
| Is Modifier | false |
| Summary | false |
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. |
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 40. DiagnosticReport.result:drFinding | |
| Slice Name | drFinding |
| Definition | Observations that are part of this diagnostic report. |
| Short | Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.Observations |
| Comments | Observations can contain observations. |
| Control | 0..2* |
| Type | Reference(Retina Diabetic Retinopathy Finding, Observation) |
| Is Modifier | false |
| Summary | false |
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. |
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 42. DiagnosticReport.result:imageQuality | |
| Slice Name | imageQuality |
| Definition | Observations that are part of this diagnostic report. |
| Short | Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.Observations |
| Comments | Observations can contain observations. |
| Control | 0..2* |
| Type | Reference(Retina Image Quality Assessment, Observation) |
| Is Modifier | false |
| Summary | false |
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. |
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 44. DiagnosticReport.imagingStudy | |
| Definition | References to ImagingStudy resources that contain the retinal images analyzed for this examination. One 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. |
| Short | Reference to imaging studies containing retinal images.Reference to full details of imaging associated with the diagnostic report |
| Comments | 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. |
| Control | 0..* |
| Type | Reference(Retina ImagingStudy, ImagingStudy) |
| Is Modifier | false |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 46. DiagnosticReport.conclusion | |
| Definition | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. |
| Short | Clinical conclusion (interpretation) of test results |
| Control | 0..01 |
| Type | string |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | false |
| Requirements | Need to be able to provide a conclusion that is not lost among the basic result data. |
| Alternate Names | Report |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 48. DiagnosticReport.conclusionCode | |
| Definition | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. |
| Short | Conclusion codes summarizing the findings of the retina examination.Codes for the clinical conclusion of test results |
| Control | 0..* |
| Binding | The codes SHALL be taken from For example codes, see Retina Conclusionhttp://hl7.org/fhir/ValueSet/clinical-findings|4.0.1 (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-conclusion-code-vs) |
| Type | CodeableConcept |
| Is Modifier | false |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be foundhere
| 0. DiagnosticReport | |
| 2. DiagnosticReport.implicitRules | |
| Control | 0..0 |
| 4. DiagnosticReport.extension | |
| Slicing | This element introduces a set of slices on DiagnosticReport.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 6. DiagnosticReport.extension:daysUntilNextExamination | |
| Slice Name | daysUntilNextExamination |
| Control | 0..1 |
| Type | Extension(Days Until Next Examination) (Extension Type: integer) |
| 8. DiagnosticReport.extension:cautions | |
| Slice Name | cautions |
| Control | 0..* |
| Type | Extension(Cautions) (Extension Type: CodeableConcept) |
| 10. DiagnosticReport.extension:previousExaminationConclusion | |
| Slice Name | previousExaminationConclusion |
| Control | 0..1 |
| Type | Extension(Previous Examination Conclusion) (Extension Type: Coding) |
| 12. DiagnosticReport.modifierExtension | |
| Control | 0..0 |
| 14. DiagnosticReport.identifier | |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 1..? |
| Slicing | This element introduces a set of slices on DiagnosticReport.identifier. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 16. DiagnosticReport.identifier:retinaExaminationId | |
| Slice Name | retinaExaminationId |
| Definition | Identifies the retina examination in RetinaIntegration. Value must be a valid GUID in format: xxxxxxxx-xxxx-xxxx-xxxx-xxxxxxxxxxxx |
| Short | Retina Examination Identifier (GUID) |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 1..1 |
| Example | UUID Identifier: { "system" : "http://dips.no/fhir/RetinaIntegration/examination-id", "value" : "550e8400-e29b-41d4-a716-446655440000" } |
| 18. DiagnosticReport.identifier:retinaExaminationId.use | |
| Control | 0..0 |
| 20. DiagnosticReport.identifier:retinaExaminationId.system | |
| Control | 1..? |
| Pattern Value | http://dips.no/fhir/RetinaIntegration/examination-id |
| 22. DiagnosticReport.identifier:retinaExaminationId.value | |
| Short | Unique identifier for the examination (GUID) |
| Control | 1..? |
| 24. DiagnosticReport.status | |
| Definition | Use 'preliminary' when the examination is created and awaiting AI/manual grading. Use 'final' when grading is complete. |
| Short | Status of the diagnostic report: registered | partial | final |
| 26. DiagnosticReport.code | |
| Definition | The type(s) of retinal imaging procedure(s) the photographer has indicated shall be performed. |
| Short | Retina imaging procedure(s) performed: fundus photography and/or OCT |
| Binding | The codes SHALL be taken from Retina Imaging Procedures (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-imaging-procedure-vs) |
| 28. DiagnosticReport.subject | |
| Definition | A reference to the patient. The patient's identifier MUST be one of the official Norwegian patient identifier systems: Fødselsnummer (urn:oid:2.16.578.1.12.4.1.4.1), D-nummer (urn:oid:2.16.578.1.12.4.1.4.2), or Felles hjelpenummer (urn:oid:2.16.578.1.12.4.1.4.3). |
| Short | Reference to the patient |
| Type | Reference(Patient) |
| Example | Patient with Fødselsnummer: {
"reference" : "Patient/cdp1000807",
"identifier" : {
"system" : "urn:oid:2.16.578.1.12.4.1.4.1",
"value" : "15076500565"
}
} Patient with D-nummer: { "reference" : "Patient/cdp1004445", "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.2", "value" : "41018512345" } } Patient with Felles Hjelpenummer: { "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.3", "value" : "11223344556" } } |
| 30. DiagnosticReport.performer | |
| Control | 0..0 |
| 32. DiagnosticReport.resultsInterpreter | |
| Control | 0..0 |
| 34. DiagnosticReport.result | |
| Slicing | This element introduces a set of slices on DiagnosticReport.result. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 36. DiagnosticReport.result:hbA1cObservation | |
| Slice Name | hbA1cObservation |
| Short | Optional HbA1c Laboratory Result |
| Control | 0..1 |
| Type | Reference(Retina HbA1c Observation) |
| 38. DiagnosticReport.result:dmeFinding | |
| Slice Name | dmeFinding |
| Short | Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. |
| Control | 0..2 |
| Type | Reference(Retina Diabetic Macular Edema Finding) |
| 40. DiagnosticReport.result:drFinding | |
| Slice Name | drFinding |
| Short | Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. |
| Control | 0..2 |
| Type | Reference(Retina Diabetic Retinopathy Finding) |
| 42. DiagnosticReport.result:imageQuality | |
| Slice Name | imageQuality |
| Short | Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. |
| Control | 0..2 |
| Type | Reference(Retina Image Quality Assessment) |
| 44. DiagnosticReport.imagingStudy | |
| Definition | References to ImagingStudy resources that contain the retinal images analyzed for this examination. |
| Short | Reference to imaging studies containing retinal images. |
| Type | Reference(Retina ImagingStudy) |
| 46. DiagnosticReport.conclusion | |
| Control | 0..0 |
| 48. DiagnosticReport.conclusionCode | |
| Short | Conclusion codes summarizing the findings of the retina examination. |
| Binding | The codes SHALL be taken from Retina Conclusion (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-conclusion-code-vs) |
Guidance on how to interpret the contents of this table can be foundhere
| 0. DiagnosticReport | |||||
| Definition | The 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. | ||||
| Short | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
| Comments | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | ||||
| Control | 0..* | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | Report, Test, Result, Results, Labs, Laboratory | ||||
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty())dom-6: A resource should have narrative for robust management ( text.`div`.exists()) | ||||
| 2. DiagnosticReport.id | |||||
| Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
| Short | Logical id of this artifact | ||||
| Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
| Control | 0..1 | ||||
| Type | id | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| 4. DiagnosticReport.meta | |||||
| Definition | The 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. | ||||
| Short | Metadata about the resource | ||||
| Control | 0..1 | ||||
| Type | Meta | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 6. DiagnosticReport.implicitRules | |||||
| Definition | A 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. | ||||
| Short | A set of rules under which this content was created | ||||
| Comments | 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. | ||||
| Control | 0..0 | ||||
| Type | uri | ||||
| Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 8. DiagnosticReport.language | |||||
| Definition | The base language in which the resource is written. | ||||
| Short | Language of the resource content | ||||
| Comments | 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). | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages|4.0.1)A human language.
| ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 10. DiagnosticReport.text | |||||
| Definition | A 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. | ||||
| Short | Text summary of the resource, for human interpretation | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | narrative, html, xhtml, display | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 12. DiagnosticReport.contained | |||||
| Definition | These 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. | ||||
| Short | Contained, inline Resources | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Resource | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | inline resources, anonymous resources, contained resources | ||||
| 14. DiagnosticReport.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| Slicing | This element introduces a set of slices on DiagnosticReport.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 16. DiagnosticReport.extension:daysUntilNextExamination | |||||
| Slice Name | daysUntilNextExamination | ||||
| Definition | Number of days until next examination. | ||||
| Short | Days Until Next Examination | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(Days Until Next Examination) (Extension Type: integer) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 18. DiagnosticReport.extension:cautions | |||||
| Slice Name | cautions | ||||
| Definition | Special considerations or cautions for grading this examination (5000-series). | ||||
| Short | Cautions | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(Cautions) (Extension Type: CodeableConcept) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 20. DiagnosticReport.extension:previousExaminationConclusion | |||||
| Slice Name | previousExaminationConclusion | ||||
| Definition | The conclusion from the previous examination (1000 series). If this is the first examination, this extension is not present. | ||||
| Short | Previous Examination Conclusion | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(Previous Examination Conclusion) (Extension Type: Coding) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 22. DiagnosticReport.modifierExtension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..0 | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 24. DiagnosticReport.identifier | |||||
| Definition | Identifiers assigned to this report by the performer or other systems. | ||||
| Short | Business identifier for report | ||||
| Comments | Usually assigned by the Information System of the diagnostic service provider (filler id). | ||||
| Note | This is a business identifier, not a resource identifier (see discussion) | ||||
| Control | 1..* | ||||
| Type | Identifier | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Alternate Names | ReportID, Filler ID, Placer ID | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on DiagnosticReport.identifier. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 26. DiagnosticReport.identifier:retinaExaminationId | |||||
| Slice Name | retinaExaminationId | ||||
| Definition | Identifies the retina examination in RetinaIntegration. Value must be a valid GUID in format: xxxxxxxx-xxxx-xxxx-xxxx-xxxxxxxxxxxx | ||||
| Short | Retina Examination Identifier (GUID) | ||||
| Comments | Usually assigned by the Information System of the diagnostic service provider (filler id). | ||||
| Note | This is a business identifier, not a resource identifier (see discussion) | ||||
| Control | 1..1 | ||||
| Type | Identifier | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Alternate Names | ReportID, Filler ID, Placer ID | ||||
| Example | UUID Identifier: { "system" : "http://dips.no/fhir/RetinaIntegration/examination-id", "value" : "550e8400-e29b-41d4-a716-446655440000" } | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 28. DiagnosticReport.identifier:retinaExaminationId.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 30. DiagnosticReport.identifier:retinaExaminationId.extension | |||||
| Definition | May 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. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| Slicing | This element introduces a set of slices on DiagnosticReport.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 32. DiagnosticReport.identifier:retinaExaminationId.use | |||||
| Definition | The purpose of this identifier. | ||||
| Short | usual | official | temp | secondary | old (If known) | ||||
| Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||||
| Control | 0..0 | ||||
| Binding | The codes SHALL be taken from IdentifierUse (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)Identifies the purpose for this identifier, if known . | ||||
| Type | code | ||||
| Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 34. DiagnosticReport.identifier:retinaExaminationId.type | |||||
| Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| Short | Description of identifier | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to http://hl7.org/fhir/ValueSet/identifier-type|4.0.1)A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 36. DiagnosticReport.identifier:retinaExaminationId.system | |||||
| Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||||
| Short | The namespace for the identifier value | ||||
| Comments | Identifier.system is always case sensitive. | ||||
| Control | 1..1 | ||||
| Type | uri | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Pattern Value | http://dips.no/fhir/RetinaIntegration/examination-id | ||||
| Example | General: http://www.acme.com/identifiers/patient | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 38. DiagnosticReport.identifier:retinaExaminationId.value | |||||
| Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||||
| Short | Unique identifier for the examination (GUID) | ||||
| Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. | ||||
| Control | 1..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Example | General: 123456 | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 40. DiagnosticReport.identifier:retinaExaminationId.period | |||||
| Definition | Time period during which identifier is/was valid for use. | ||||
| Short | Time period when id is/was valid for use | ||||
| Control | 0..1 | ||||
| Type | Period | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 42. DiagnosticReport.identifier:retinaExaminationId.assigner | |||||
| Definition | Organization that issued/manages the identifier. | ||||
| Short | Organization that issued id (may be just text) | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Type | Reference(Organization) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 44. DiagnosticReport.basedOn | |||||
| Definition | Details concerning a service requested. | ||||
| Short | What was requested | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Reference(CarePlan, ImmunizationRecommendation, MedicationRequest, NutritionOrder, ServiceRequest) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. | ||||
| Alternate Names | Request | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 46. DiagnosticReport.status | |||||
| Definition | Use 'preliminary' when the examination is created and awaiting AI/manual grading. Use 'final' when grading is complete. | ||||
| Short | Status of the diagnostic report: registered | partial | final | ||||
| Control | 1..1 | ||||
| Binding | The codes SHALL be taken from DiagnosticReportStatus (required to http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1)The status of the diagnostic report. | ||||
| Type | code | ||||
| Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Requirements | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 48. DiagnosticReport.category | |||||
| Definition | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | ||||
| Short | Service category | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Binding | For example codes, see DiagnosticServiceSectionCodes (example to http://hl7.org/fhir/ValueSet/diagnostic-service-sections|4.0.1)Codes for diagnostic service sections. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Alternate Names | Department, Sub-department, Service, Discipline | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 50. DiagnosticReport.code | |||||
| Definition | The type(s) of retinal imaging procedure(s) the photographer has indicated shall be performed. | ||||
| Short | Retina imaging procedure(s) performed: fundus photography and/or OCT | ||||
| Control | 1..1 | ||||
| Binding | The codes SHALL be taken from Retina Imaging Procedures (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-imaging-procedure-vs) | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Alternate Names | Type | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 52. DiagnosticReport.subject | |||||
| Definition | A reference to the patient. The patient's identifier MUST be one of the official Norwegian patient identifier systems: Fødselsnummer (urn:oid:2.16.578.1.12.4.1.4.1), D-nummer (urn:oid:2.16.578.1.12.4.1.4.2), or Felles hjelpenummer (urn:oid:2.16.578.1.12.4.1.4.3). | ||||
| Short | Reference to the patient | ||||
| Control | 0..1 | ||||
| Type | Reference(Patient) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | SHALL know the subject context. | ||||
| Alternate Names | Patient | ||||
| Example | Patient with Fødselsnummer: {
"reference" : "Patient/cdp1000807",
"identifier" : {
"system" : "urn:oid:2.16.578.1.12.4.1.4.1",
"value" : "15076500565"
}
} Patient with D-nummer: { "reference" : "Patient/cdp1004445", "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.2", "value" : "41018512345" } } Patient with Felles Hjelpenummer: { "identifier" : { "system" : "urn:oid:2.16.578.1.12.4.1.4.3", "value" : "11223344556" } } | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 54. DiagnosticReport.encounter | |||||
| Definition | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | ||||
| Short | Health care event when test ordered | ||||
| Comments | 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). | ||||
| Control | 0..1 | ||||
| Type | Reference(Encounter) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Links the request to the Encounter context. | ||||
| Alternate Names | Context | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 56. DiagnosticReport.effective[x] | |||||
| Definition | The 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. | ||||
| Short | Clinically relevant time/time-period for report | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Type | Choice of: dateTime, Period | ||||
| [x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Requirements | Need to know where in the patient history to file/present this report. | ||||
| Alternate Names | Observation time, Effective Time, Occurrence | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 58. DiagnosticReport.issued | |||||
| Definition | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | ||||
| Short | DateTime this version was made | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Type | instant | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Requirements | Clinicians need to be able to check the date that the report was released. | ||||
| Alternate Names | Date published, Date Issued, Date Verified | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 60. DiagnosticReport.performer | |||||
| Definition | The diagnostic service that is responsible for issuing the report. | ||||
| Short | Responsible Diagnostic Service | ||||
| Comments | 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. | ||||
| Control | 0..0 | ||||
| Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Alternate Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 62. DiagnosticReport.resultsInterpreter | |||||
| Definition | The practitioner or organization that is responsible for the report's conclusions and interpretations. | ||||
| Short | Primary result interpreter | ||||
| Comments | Might not be the same entity that takes responsibility for the clinical report. | ||||
| Control | 0..0 | ||||
| Type | Reference(Practitioner, PractitionerRole, Organization, CareTeam) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Alternate Names | Analyzed by, Reported by | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 64. DiagnosticReport.specimen | |||||
| Definition | Details about the specimens on which this diagnostic report is based. | ||||
| Short | Specimens this report is based on | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Reference(Specimen) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to be able to report information about the collected specimens on which the report is based. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 66. DiagnosticReport.result | |||||
| Definition | Observations that are part of this diagnostic report. | ||||
| Short | Observations | ||||
| Comments | Observations can contain observations. | ||||
| Control | 0..* | ||||
| Type | Reference(Observation) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. | ||||
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on DiagnosticReport.result. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 68. DiagnosticReport.result:hbA1cObservation | |||||
| Slice Name | hbA1cObservation | ||||
| Definition | Observations that are part of this diagnostic report. | ||||
| Short | Optional HbA1c Laboratory Result | ||||
| Comments | Observations can contain observations. | ||||
| Control | 0..1 | ||||
| Type | Reference(Retina HbA1c Observation) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. | ||||
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 70. DiagnosticReport.result:dmeFinding | |||||
| Slice Name | dmeFinding | ||||
| Definition | Observations that are part of this diagnostic report. | ||||
| Short | Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. | ||||
| Comments | Observations can contain observations. | ||||
| Control | 0..2 | ||||
| Type | Reference(Retina Diabetic Macular Edema Finding) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. | ||||
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 72. DiagnosticReport.result:drFinding | |||||
| Slice Name | drFinding | ||||
| Definition | Observations that are part of this diagnostic report. | ||||
| Short | Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. | ||||
| Comments | Observations can contain observations. | ||||
| Control | 0..2 | ||||
| Type | Reference(Retina Diabetic Retinopathy Finding) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. | ||||
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 74. DiagnosticReport.result:imageQuality | |||||
| Slice Name | imageQuality | ||||
| Definition | Observations that are part of this diagnostic report. | ||||
| Short | Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye. | ||||
| Comments | Observations can contain observations. | ||||
| Control | 0..2 | ||||
| Type | Reference(Retina Image Quality Assessment) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. | ||||
| Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 76. DiagnosticReport.imagingStudy | |||||
| Definition | References to ImagingStudy resources that contain the retinal images analyzed for this examination. | ||||
| Short | Reference to imaging studies containing retinal images. | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Reference(Retina ImagingStudy) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 78. DiagnosticReport.media | |||||
| Definition | A 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). | ||||
| Short | Key images associated with this report | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Many diagnostic services include images in the report as part of their service. | ||||
| Alternate Names | DICOM, Slides, Scans | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 80. DiagnosticReport.media.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 82. DiagnosticReport.media.extension | |||||
| Definition | May 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. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 84. DiagnosticReport.media.modifierExtension | |||||
| Definition | May 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). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | 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. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | 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. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 86. DiagnosticReport.media.comment | |||||
| Definition | A 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. | ||||
| Short | Comment about the image (e.g. explanation) | ||||
| Comments | 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. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | The provider of the report should make a comment about each image included in the report. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 88. DiagnosticReport.media.link | |||||
| Definition | Reference to the image source. | ||||
| Short | Reference to the image source | ||||
| Control | 1..1 | ||||
| Type | Reference(Media) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 90. DiagnosticReport.conclusion | |||||
| Definition | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | ||||
| Short | Clinical conclusion (interpretation) of test results | ||||
| Control | 0..0 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Need to be able to provide a conclusion that is not lost among the basic result data. | ||||
| Alternate Names | Report | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 92. DiagnosticReport.conclusionCode | |||||
| Definition | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | ||||
| Short | Conclusion codes summarizing the findings of the retina examination. | ||||
| Control | 0..* | ||||
| Binding | The codes SHALL be taken from Retina Conclusion (required to http://dips.no/fhir/RetinaIntegration/ValueSet/retina-conclusion-code-vs) | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 94. DiagnosticReport.presentedForm | |||||
| Definition | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | ||||
| Short | Entire report as issued | ||||
| Comments | "application/pdf" is recommended as the most reliable and interoperable in this context. | ||||
| Control | 0..* | ||||
| Type | Attachment | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||