Madeira Pilot Implementation Guide
0.1.0 - R1
Madeira Pilot Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions
Official URL: https://fhir.digit-madeira.pt/StructureDefinition/DailyPostureDiagnosticReport | Version: 0.1.0 | |||
Active as of 2023-04-27 | Computable Name: DailyPostureDiagnosticReport |
The profile defines how to represent posture data of a patient during a day (tipically, a 24 hour period). The reports relies on two observation resources containing the relevant data for good and bad posture.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
code | 1..1 | CodeableConcept | Name/Code for this diagnostic report 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |
subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
effective[x] | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |
effectivePeriod | 1..1 | Period | Clinically relevant time/time-period for report | |
start | 1..1 | dateTime | Starting time with inclusive boundary | |
end | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | |
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Closed by type:$this |
effective[x]:effectivePeriod | Σ | 1..1 | Period | Clinically relevant time/time-period for report |
start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary |
end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing |
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.code | preferred | Pattern: SNOMED CT code 298341003("Finding of body posture") |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): IETF language tag
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports 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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectivePeriod | Σ | 1..1 | Period | Clinically relevant time/time-period for report | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
issued | Σ | 0..1 | instant | DateTime this version was made | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |||||
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |||||
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
presentedForm | 0..* | Attachment | Entire report as issued | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.code | preferred | Pattern: SNOMED CT code 298341003("Finding of body posture") | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
dom-r4b | warning | DiagnosticReport.contained | Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |
subject | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | |
effective[x] | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |
effectivePeriod | 1..1 | Period | Clinically relevant time/time-period for report | |
start | 1..1 | dateTime | Starting time with inclusive boundary | |
end | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | |
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Closed by type:$this |
effective[x]:effectivePeriod | Σ | 1..1 | Period | Clinically relevant time/time-period for report |
start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary |
end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing |
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.code | preferred | Pattern: SNOMED CT code 298341003("Finding of body posture") |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): IETF language tag
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074 | ||||
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): LOINC Codes for Diagnostic Reports 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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 298341003 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Finding of body posture | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for report Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectivePeriod | Σ | 1..1 | Period | Clinically relevant time/time-period for report | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
issued | Σ | 0..1 | instant | DateTime this version was made | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
Slices for result | 2..* | Reference(Observation) | Observations Slice: Unordered, Open by value:resolve().code | |||||
result:NormalPosture | 1..1 | Reference(Normal Posture Observation) | Observations | |||||
result:PoorPosture | 1..1 | Reference(Poor Posture Observation) | Observations | |||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | Σ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): SNOMED CT Clinical Findings | |||||
presentedForm | 0..* | Attachment | Entire report as issued | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.code | preferred | Pattern: SNOMED CT code 298341003("Finding of body posture") | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
dom-r4b | warning | DiagnosticReport.contained | Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron