臺灣醫療影像與病理報告FHIR研究實作指引
0.1.0 - DSTU0 ci-build

臺灣醫療影像與病理報告FHIR研究實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DiagnosticReport LC

Official URL: https://hapi.fhir.tw/fhir/StructureDefinition/DiagnosticReport-LC Version: 0.1.0
Active as of 2024-07-29 Computable Name: DiagnosticReportLC

說明如何定義非小細胞肺癌病理報告

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 0..* CodeableConcept Service category
.... coding
..... system 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
..... code 0..1 code Symbol in syntax defined by the system
Required Pattern: LP7839-6
..... display 0..1 string Representation defined by the system
Required Pattern: Pathology
.... 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: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
... subject S 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] S 0..1 dateTime, Period 與臨床相關的時間／報告的時段
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code SΣ 1..1 CodeableConcept Name/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe 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://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 0..1 與臨床相關的時間／報告的時段
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredPattern: LOINC Code 22637-3("Pathology report final diagnosis Narrative")
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... 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
... 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 SΣ 1..1 Identifier 報告的業務用識別碼
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Required Pattern: LP7839-6
..... display Σ 0..1 string Representation defined by the system
Required Pattern: Pathology
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Name/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe 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://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: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 0..1 與臨床相關的時間／報告的時段
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... 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 S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredPattern: LOINC Code 22637-3("Pathology report final diagnosis Narrative")
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

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

This structure is derived from DiagnosticReport

Summary

Mandatory: 7 elements
Must-Support: 20 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 0..* CodeableConcept Service category
.... coding
..... system 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
..... code 0..1 code Symbol in syntax defined by the system
Required Pattern: LP7839-6
..... display 0..1 string Representation defined by the system
Required Pattern: Pathology
.... 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: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
... subject S 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] S 0..1 dateTime, Period 與臨床相關的時間／報告的時段
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code SΣ 1..1 CodeableConcept Name/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe 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://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 0..1 與臨床相關的時間／報告的時段
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredPattern: LOINC Code 22637-3("Pathology report final diagnosis Narrative")
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... 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
... 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 SΣ 1..1 Identifier 報告的業務用識別碼
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 0..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Required Pattern: LP7839-6
..... display Σ 0..1 string Representation defined by the system
Required Pattern: Pathology
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Name/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe 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://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: 22637-3
..... display 1..1 string Representation defined by the system
Fixed Value: Pathology report final diagnosis Narrative
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 0..1 與臨床相關的時間／報告的時段
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner) 對診斷服務負責者
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) 主要結果的解釋者
... specimen S 1..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation LC Gross Finding | Observation LC Histologic type | Observation LC Histologic pattern | Observation LC Cell type | Observation LC Resection margin | Observation LC Non-tumorous parenchma | Observation LC Total tumor size | Observation LC Size of invasive focus | Observation LC Angiolymphatic invasion | Observation LC Perineural invasion | Observation LC Pleural invasion | Observation LC Spread Through Air Spaces (STAS) | Observation LC Tumor necrosis | Observation LC T category | Observation LC Lymph nodes | Observation LC Metastasis | Observation LC Pathological staging | Observation LC Tumor grading | Observation LC Ancillary studies) 診斷結果
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... 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 S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 0..1 string 診斷結果的臨床結論（解釋）
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredPattern: LOINC Code 22637-3("Pathology report final diagnosis Narrative")
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

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

This structure is derived from DiagnosticReport

Summary

Mandatory: 7 elements
Must-Support: 20 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron