HL7 FHIR Implementation Guide Laboratory Report
0.2.0 - trial-use
HL7 FHIR Implementation Guide Laboratory Report
0.2.0 - trial-use
This page is part of the HL7 FHIR Implementation Guide Laboratory Report (v0.2.0: Release 1) based on FHIR (HL7® FHIR® Standard) 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
| Official URL: http://hl7.it/fhir/lab-report/StructureDefinition/composition-it-lab | Version: 0.2.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: CompositionRefertoLabIt | ||
Descrizione del referto di laboratorio tramite il profilo della risorsa Composition per il referto di laboratorio.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CompositionLabReportEu
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |
  language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Required Pattern: it-IT | |
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
 extension:information-recipient | 0..* | InformationRecipient | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). | |
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |
| identifier | 1..1 | Identifier | Identificativo indipendente dalla versione. | |
| status | 1..1 | code | Stato del Referto | |
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio | |
| category | 0..* | CodeableConceptIPS | Report Category | |
 subject | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | |
| encounter | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | |
| date | 1..1 | dateTime | Data di modifica della risorsa Composition. | |
| author | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | |
| title | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | |
| confidentiality | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | |
  Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |
  attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |
  mode | 1..1 | code | The type of attestation Required Pattern: legal | |
| time | 1..1 | dateTime | Riferimento temporale della firma. | |
 party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |
 attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |
 mode | 1..1 | code | The type of attestation Required Pattern: professional | |
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |
| custodian | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | |
| section | 1..* | BackboneElement | Composition is broken into sections | |
| title | 1..1 | string | Titolo della sezione. | |
 code | 1..1 | CodeableConceptIPS | Codice della sezione. | |
| section:lab-no-subsections | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
| entry | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | |
| section:lab-subsections | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |
| entry | 0..0 | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | ||
| section | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | |
 section:annotations | 0..* | BackboneElement | Commenti testuali | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) | |
| text | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | |
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | |
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |||||
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Binding: CommonLanguages (preferred): A human language.
Required Pattern: it-IT | |||||
 text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
 extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
 Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
 value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
| diagnosticReport-reference | 0..1 | Reference(DiagnosticReport) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
| value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 1..1 | Identifier | Identificativo indipendente dalla versione. | ||||
| status | ?!Σ | 1..1 | code | Stato del Referto Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
 category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | ||||
| date | Σ | 1..1 | dateTime | Data di modifica della risorsa Composition. | ||||
| author | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | ||||
| title | Σ | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | ||||
| confidentiality | Σ | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | ||||
| Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | |||||
| time | 1..1 | dateTime | Riferimento temporale della firma. | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |||||
| attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |||||
| custodian | Σ | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Titolo della sezione. | |||||
| code | 1..1 | CodeableConceptIPS | Codice della sezione. Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| text | C | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| entry | C | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| section | C | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| section:annotations | C | 0..* | BackboneElement | Commenti testuali cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
 code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| text | C | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | Pattern: it-IT
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab | ||||
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legalAuthenticator.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:authenticator.mode | required | Pattern: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Binding: CommonLanguages (preferred): A human language.
Required Pattern: it-IT | |||||
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
| value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |||||
| diagnosticReport-reference | 0..1 | Reference(DiagnosticReport) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
| value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 1..1 | Identifier | Identificativo indipendente dalla versione. | ||||
| status | ?!Σ | 1..1 | code | Stato del Referto Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | ||||
| date | Σ | 1..1 | dateTime | Data di modifica della risorsa Composition. | ||||
| author | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | ||||
| title | Σ | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | ||||
| confidentiality | Σ | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | ||||
| Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |||||
| attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | |||||
| time | 1..1 | dateTime | Riferimento temporale della firma. | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |||||
| attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |||||
| custodian | Σ | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented | ||||
| 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 | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | Period of time covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| title | 1..1 | string | Titolo della sezione. | |||||
| code | 1..1 | CodeableConceptIPS | Codice della sezione. Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:annotations | C | 0..* | BackboneElement | Commenti testuali cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | Pattern: it-IT
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.extension:diagnosticReport-reference.value[x].type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab | ||||
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legalAuthenticator.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:authenticator.mode | required | Pattern: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-no-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-no-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.section:lab-subsections.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-subsections.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:annotations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:annotations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:annotations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | 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 CompositionLabReportEu
Summary
Mandatory: 3 elements (7 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from CompositionLabReportEu
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |
| language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Required Pattern: it-IT | |
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
| extension:information-recipient | 0..* | InformationRecipient | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). | |
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |
| identifier | 1..1 | Identifier | Identificativo indipendente dalla versione. | |
| status | 1..1 | code | Stato del Referto | |
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio | |
| category | 0..* | CodeableConceptIPS | Report Category | |
| subject | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | |
| encounter | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | |
| date | 1..1 | dateTime | Data di modifica della risorsa Composition. | |
| author | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | |
| title | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | |
| confidentiality | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | |
| Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |
| attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |
| mode | 1..1 | code | The type of attestation Required Pattern: legal | |
| time | 1..1 | dateTime | Riferimento temporale della firma. | |
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |
| attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |
| mode | 1..1 | code | The type of attestation Required Pattern: professional | |
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |
| custodian | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | |
| section | 1..* | BackboneElement | Composition is broken into sections | |
| title | 1..1 | string | Titolo della sezione. | |
| code | 1..1 | CodeableConceptIPS | Codice della sezione. | |
| section:lab-no-subsections | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
| entry | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | |
| section:lab-subsections | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |
| entry | 0..0 | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | ||
| section | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | |
| section:annotations | 0..* | BackboneElement | Commenti testuali | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Classification of section (recommended) | |
| text | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | |
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | |
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Binding: CommonLanguages (preferred): A human language.
Required Pattern: it-IT | |||||
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
| diagnosticReport-reference | 0..1 | Reference(DiagnosticReport) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
| value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 1..1 | Identifier | Identificativo indipendente dalla versione. | ||||
| status | ?!Σ | 1..1 | code | Stato del Referto Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | ||||
| date | Σ | 1..1 | dateTime | Data di modifica della risorsa Composition. | ||||
| author | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | ||||
| title | Σ | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | ||||
| confidentiality | Σ | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | ||||
| Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | |||||
| time | 1..1 | dateTime | Riferimento temporale della firma. | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |||||
| attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |||||
| custodian | Σ | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Titolo della sezione. | |||||
| code | 1..1 | CodeableConceptIPS | Codice della sezione. Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| text | C | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| entry | C | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| section | C | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| section:annotations | C | 0..* | BackboneElement | Commenti testuali cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| text | C | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | Pattern: it-IT
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab | ||||
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legalAuthenticator.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:authenticator.mode | required | Pattern: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | CompositionLabReportEu | Composition Referto di Laboratorio | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 1..1 | code | Metadato che indica la lingua utilizzata per descrivere la risorsa. Binding: CommonLanguages (preferred): A human language.
Required Pattern: it-IT | |||||
| text | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| basedOn-order-or-requisition | 0..* | Identifier, Reference(ServiceRequest) | Document Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition" | |||||
| Slices for value[x] | 0..1 | Reference(ServiceRequest) | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 0..1 | Reference(ServiceRequest: Laboratory Order) | Value of extension | |||||
| information-recipient | 0..* | Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) | Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS). URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
| value[x] | 0..1 | Reference(Practitioner: Laboratory Report | Device | Patient: Person | RelatedPerson | PractitionerRole: Laboratory Report | Organization) | Value of extension | |||||
| diagnosticReport-reference | 0..1 | Reference(DiagnosticReport) | Document DiagnosticReport Reference URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference" | |||||
| value[x] | 1..1 | Reference(DiagnosticReport: Laboratory Report) | Value of extension | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| dataEnterer | 0..* | (Complex) | Persona o dispositivo che trasforma un testo dettato nel documento FHIR. URL: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 1..1 | Identifier | Identificativo indipendente dalla versione. | ||||
| status | ?!Σ | 1..1 | code | Stato del Referto Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | 1..1 | CodeableConceptIPS | Referto di Laboratorio Binding: Laboratory Report Types (preferred) | |||||
| Slices for category | Σ | 0..* | CodeableConceptIPS | Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:studyType | Σ | 0..* | CodeableConcept | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: Laboratory Study Types (required) | ||||
| category:specialty | Σ | 0..* | CodeableConcept | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) Binding: Laboratory Specialty (required) | ||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Who and/or what this report is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Evento sanitario a cui si riferisce il Referto di Laboratorio (es. al momento della prescrizione). | ||||
| date | Σ | 1..1 | dateTime | Data di modifica della risorsa Composition. | ||||
| author | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Patient - Lab Report | Organization - Lab Report) | Chi e/o cosa è l'autore del referto di laboratorio. | ||||
| title | Σ | 1..1 | string | Titolo o nome human-readable della Composition. Required Pattern: Referto di Laboratorio | ||||
| confidentiality | Σ | 0..1 | code | Codice di confidenzialità della Composition. Binding: Confidentiality (required) | ||||
| Slices for attester | 1..* | BackboneElement | Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento. Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the report | |||||
| attester:legalAuthenticator | 0..1 | BackboneElement | Firmatario del documento FHIR. | |||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | |||||
| time | 1..1 | dateTime | Riferimento temporale della firma. | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al firmatario. | |||||
| attester:authenticator | 0..1 | BackboneElement | Validatore del documento FHIR. | |||||
| 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 | ||||
| mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | |||||
| time | 0..1 | dateTime | When the report was attested by the party | |||||
| party | 0..1 | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report) | Riferimento al validatore. | |||||
| custodian | Σ | 0..1 | Reference(Organization - Lab Report) | Organizzazione che si occupa della conservazione del documento FHIR. | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The laboratory service(s) being documented | ||||
| 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 | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the laboratory service(s) being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | Period of time covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The laboratory service(s) being documented | ||||
| Slices for section | C | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by exists:$this.section, exists:$this.entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| title | 1..1 | string | Titolo della sezione. | |||||
| code | 1..1 | CodeableConceptIPS | Codice della sezione. Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-no-subsections | C | 0..* | BackboneElement | Variante 1: questa sezione presenta solo entry senza sottosezioni. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation - Lab Report | Observation battery - Lab Report | Observation Document - Lab Report) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:lab-subsections | C | 0..* | BackboneElement | Variante 2: questa sezione presenta sottosezioni senza entry cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Sezioni Composition Lab Report (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 1..* | BackboneElement | Sottosezione strutturata della sezione principale. | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Laboratory Study Types (preferred) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Observation Results: laboratory) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section:annotations | C | 0..* | BackboneElement | Commenti testuali cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title | 1..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48767-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 1..1 | Narrative | Sintesi testuale della sezione, per l'interpretazione dell'utente. | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | Pattern: it-IT
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.extension:diagnosticReport-reference.value[x].type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | LabReportTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.category:studyType | required | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.category:specialty | required | LabSpecialtyEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab | ||||
| Composition.confidentiality | required | Confidentialityhttp://terminology.hl7.org/ValueSet/v3-Confidentiality | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legalAuthenticator.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:authenticator.mode | required | Pattern: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-no-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-no-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-no-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.code | preferred | VsSezioniRefertoLaboratoriohttp://hl7.it/fhir/lab-report/ValueSet/sezione-referto-laboratoriofrom this IG | ||||
| Composition.section:lab-subsections.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-subsections.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.section.code | preferred | LabStudyTypesEuVshttp://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab | ||||
| Composition.section:lab-subsections.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-subsections.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-subsections.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:annotations.code | example | Pattern: LOINC code 48767-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:annotations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:annotations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:annotations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-no-subsections, Composition.section:lab-subsections, Composition.section:annotations | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | 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 CompositionLabReportEu
Summary
Mandatory: 3 elements (7 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron