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

Resource Profile: Retina DiagnosticReport

Official URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/retina-diagnostic-report Version: 0.5.0
Draft as of 2025-12-08 Computable Name: RetinaDiagnosticReport

Diagnostic report for the grading process of a single examination which is part of a screening program.

The purpose of RetinaIntegrationDiagnosticReport is for a client to examine the state of a retina screening examination grading. This includes documenting which observations were made (e.g., fundus photography, OCT), any laboratory results relevant to the examination (e.g., HbA1c), and the results of AI analysis or manual grading for diabetic retinopathy (DR) and diabetic macular edema (DME). Additionally, it captures metadata about the examination, such as identifiers, image quality, and recommended follow-up actions.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... Slices for identifier Σ 1..* Identifier Business identifier for report
Slice: Unordered, Open by value:system
.... identifier:retinaExaminationId Σ 1..1 Identifier Retina Examination Identifier (GUID)

Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... system Σ 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value Σ 1..1 string Unique identifier for the examination (GUID)
Example General: 123456
... status ?!Σ 1..1 code Status of the diagnostic report: registered | partial | final
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... subject Σ 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG

Constraints

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules 0..0 A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... modifierExtension 0..0 Extension
.... identifier:retinaExaminationId 1..1 Identifier Retina Examination Identifier (GUID)
Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... use 0..0 usual | official | temp | secondary | old (If known)
..... system 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value 1..1 string Unique identifier for the examination (GUID)
... status 1..1 code Status of the diagnostic report: registered | partial | final
... code 1..1 CodeableConcept Retina imaging procedure(s) performed: fundus photography and/or OCT
Binding: Retina Imaging Procedures (required)
... subject 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... performer 0..0 Responsible Diagnostic Service
... resultsInterpreter 0..0 Primary result interpreter
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... conclusion 0..0 Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... Slices for identifier Σ 1..* Identifier Business identifier for report
Slice: Unordered, Open by value:system
.... identifier:retinaExaminationId Σ 1..1 Identifier Retina Examination Identifier (GUID)

Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system Σ 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value Σ 1..1 string Unique identifier for the examination (GUID)
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!Σ 1..1 code Status of the diagnostic report: registered | partial | final
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category Σ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
... code Σ 1..1 CodeableConcept Retina imaging procedure(s) performed: fundus photography and/or OCT
Binding: Retina Imaging Procedures (required)
... subject Σ 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] Σ 0..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... specimen 0..* Reference(Specimen) Specimens this report is based on
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)
... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.identifier:retinaExaminationId.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG

Constraints

Id Grade Path(s) Description Expression
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... Slices for identifier Σ 1..* Identifier Business identifier for report
Slice: Unordered, Open by value:system
.... identifier:retinaExaminationId Σ 1..1 Identifier Retina Examination Identifier (GUID)

Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... system Σ 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value Σ 1..1 string Unique identifier for the examination (GUID)
Example General: 123456
... status ?!Σ 1..1 code Status of the diagnostic report: registered | partial | final
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... subject Σ 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG

Constraints

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

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules 0..0 A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... modifierExtension 0..0 Extension
.... identifier:retinaExaminationId 1..1 Identifier Retina Examination Identifier (GUID)
Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... use 0..0 usual | official | temp | secondary | old (If known)
..... system 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value 1..1 string Unique identifier for the examination (GUID)
... status 1..1 code Status of the diagnostic report: registered | partial | final
... code 1..1 CodeableConcept Retina imaging procedure(s) performed: fundus photography and/or OCT
Binding: Retina Imaging Procedures (required)
... subject 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... performer 0..0 Responsible Diagnostic Service
... resultsInterpreter 0..0 Primary result interpreter
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... conclusion 0..0 Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:daysUntilNextExamination 0..1 integer Days Until Next Examination
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/days-until-next-examination-extension
.... extension:cautions 0..* CodeableConcept Cautions
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/cautions-extension
Binding: Retina Cautions (required)
.... extension:previousExaminationConclusion 0..1 Coding Previous Examination Conclusion
URL: http://dips.no/fhir/RetinaIntegration/StructureDefinition/previous-examination-conclusion-extension
Binding: Retina Conclusion (required)
... Slices for identifier Σ 1..* Identifier Business identifier for report
Slice: Unordered, Open by value:system
.... identifier:retinaExaminationId Σ 1..1 Identifier Retina Examination Identifier (GUID)

Example UUID Identifier: {"system":"http://dips.no/fhir/RetinaIntegration/examination-id","value":"550e8400-e29b-41d4-a716-446655440000"}
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system Σ 1..1 uri The namespace for the identifier value
Required Pattern: http://dips.no/fhir/RetinaIntegration/examination-id
..... value Σ 1..1 string Unique identifier for the examination (GUID)
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!Σ 1..1 code Status of the diagnostic report: registered | partial | final
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category Σ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
... code Σ 1..1 CodeableConcept Retina imaging procedure(s) performed: fundus photography and/or OCT
Binding: Retina Imaging Procedures (required)
... subject Σ 0..1 Reference(Patient) Reference to the patient
Example Patient with Fødselsnummer: {"reference":"Patient/cdp1000807","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.1","value":"15076500565"}}
Example Patient with D-nummer: {"reference":"Patient/cdp1004445","identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.2","value":"41018512345"}}
Example Patient with Felles Hjelpenummer: {"identifier":{"system":"urn:oid:2.16.578.1.12.4.1.4.3","value":"11223344556"}}
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] Σ 0..1 Clinically relevant time/time-period for report
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... specimen 0..* Reference(Specimen) Specimens this report is based on
... Slices for result 0..* Reference(Observation) Observations
Slice: Unordered, Open by profile:resolve()
.... result:hbA1cObservation 0..1 Reference(Retina HbA1c Observation) Optional HbA1c Laboratory Result
.... result:dmeFinding 0..2 Reference(Retina Diabetic Macular Edema Finding) Optional DME Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:drFinding 0..2 Reference(Retina Diabetic Retinopathy Finding) Optional DR Findings (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
.... result:imageQuality 0..2 Reference(Retina Image Quality Assessment) Optional Image Quality Observations (up to 2: left and/or right eye). Use bodySite element to distinguish left vs right eye.
... imagingStudy 0..* Reference(Retina ImagingStudy) Reference to imaging studies containing retinal images.
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusionCode 0..* CodeableConcept Conclusion codes summarizing the findings of the retina examination.
Binding: Retina Conclusion (required)
... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.identifier:retinaExaminationId.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base required Retina Imaging Procedures 📦0.5.0 This IG
DiagnosticReport.conclusionCode Base required Retina Conclusion 📦0.5.0 This IG

Constraints

Id Grade Path(s) Description Expression
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()

 

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