HL7 FHIR Implementation Guide Laboratory Report
0.1.0 - ballot Italy flag

This page is part of the HL7 FHIR Implementation Guide Laboratory Report (v0.1.0: Release 1 Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: DiagnosticReport - Lab Report

Official URL: http://hl7.it/fhir/lab-report/StructureDefinition/diagnosticreport-it-lab Version: 0.1.0
Draft as of 2023-07-11 Computable Name: DiagnosticReportRefertoLabIt

Copyright/Legal: HL7 Italia

Descrizione della risorsa DiagnosticReport per la descrizione delle informazioni cliniche del dominio di Lab Report.

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... category 1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code 1..1CodeableConceptNome/codice della diagnostic report.
.... coding 0..*CodingCodice definito da un sistema terminologico.
..... system 0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... code 0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display 0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
... subject 1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter 0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... performer 0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... imagingStudy 0..0
... media 0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... comment 0..1stringCommento sull'immagine.
.... link 1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... status ?!Σ1..1codeDescrizione attributo: Stato del report clinico. Possibili valori: registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required)
... category Σ1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code Σ1..1CodeableConceptNome/codice della diagnostic report.
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... coding Σ0..*CodingCodice definito da un sistema terminologico.
..... system Σ0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... code Σ0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display Σ0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
... subject Σ1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter Σ0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... performer Σ0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... media Σ0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringCommento sull'immagine.
.... link Σ1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... status ?!Σ1..1codeDescrizione attributo: Stato del report clinico. Possibili valori: registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required)
... category Σ1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code Σ1..1CodeableConceptNome/codice della diagnostic report.
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCodice definito da un sistema terminologico.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display Σ0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter Σ0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... media Σ0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringCommento sull'immagine.
.... link Σ1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... category 1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code 1..1CodeableConceptNome/codice della diagnostic report.
.... coding 0..*CodingCodice definito da un sistema terminologico.
..... system 0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... code 0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display 0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
... subject 1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter 0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... performer 0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... imagingStudy 0..0
... media 0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... comment 0..1stringCommento sull'immagine.
.... link 1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... status ?!Σ1..1codeDescrizione attributo: Stato del report clinico. Possibili valori: registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required)
... category Σ1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code Σ1..1CodeableConceptNome/codice della diagnostic report.
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... coding Σ0..*CodingCodice definito da un sistema terminologico.
..... system Σ0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... code Σ0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display Σ0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
... subject Σ1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter Σ0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... performer Σ0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... media Σ0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringCommento sull'immagine.
.... link Σ1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportDiagnosticReport Referto di Laboratorio
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReportCompositionR5 0..1Reference(Composition)Estensione di FHIR R5 per legare la DiagnosticReport a Composition.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition"
.... value[x] 1..1Reference(Composition - Lab Report)Reference a Composition.
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest - Lab Report)Reference a una o più prestazioni richieste associate al referto.
... status ?!Σ1..1codeDescrizione attributo: Stato del report clinico. Possibili valori: registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown
Binding: DiagnosticReportStatus (required)
... category Σ1..*CodeableConceptCategoria del servizio.
Binding: DiagnosticServiceSectionCodes (example)
... code Σ1..1CodeableConceptNome/codice della diagnostic report.
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCodice definito da un sistema terminologico.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriSistema terminologico.
Required Pattern: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ0..1codeCodice appartenente al sistema terminologico.
Required Pattern: 11502-2
..... display Σ0..1stringDescrizione del codice.
Required Pattern: Referto di medicina di laboratorio
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ1..1Reference(Patient - Lab Report)Soggetto del referto.
... encounter Σ0..1Reference(Encounter - Lab Report)Contesto in cui è stato generato il DiagnosticReport.
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam)Responsabile del report clinico.
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen - Lab Report)Reference ai campioni su cui si basa DiagnosticReport.
... result 0..*Reference(Observation - Lab Report | Observation battery - Lab Report)Osservazioni cliniche.
... media Σ0..*BackboneElementContenuto multimediale associate al DiagnosticReport.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringCommento sull'immagine.
.... link Σ1..1Reference(Media - Lab Report)Riferimento al contenuto multimediale.
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron