Nictiz FHIR NL R4 Zib2020
0.9.0 - CI Build
Nictiz FHIR NL R4 Zib2020
0.9.0 - CI Build
Nictiz FHIR NL R4 Zib2020 - Local Development build (v0.9.0). See the Directory of published versions
| Official URL: http://nictiz.nl/fhir/StructureDefinition/nl-core-TextResult | Version: 0.9.0 | |||
| Draft as of 2023-10-17 | Computable Name: NlcoreTextResult | |||
Copyright/Legal: Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise. |
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Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.
A derived profile from zib-TextResult to provide a version better suited for implementation purposes. This profile augments the base profile with elements found in the various use cases that have adopted the zib.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ZibTextResult
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | ZibTextResult | TextResult | |
  subject | 0..1 | Reference(Patient | Group | Device | Location | nl core Patient) | The subject of the report - usually, but not always, the patient | |
  media | ||||
  link | 1..1 | Reference(Media | nl core TextResult.VisualResult) | Reference to the image source | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | ZibTextResult | TextResult | |
 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 | TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus. |
  textResultStatus | 0..1 | CodeableConcept | Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification | |
 url | 1..1 | uri | "http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification" | |
 code | Σ | 1..1 | CodeableConcept | TextResultType Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 (extensible) |
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | nl core Patient) | The subject of the report - usually, but not always, the patient |
 Slices for effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |
 effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
 effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | TextResultDateTime |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.code | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 |
| 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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | ZibTextResult | TextResult | |||||
| 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): A human language.
| |||||
| 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 | TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus. | ||||
| id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| textResultStatus | 0..1 | CodeableConcept | Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification | |||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| url | 1..1 | uri | "http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification" | |||||
| value[x] | 0..1 | CodeableConcept | TextResultStatus Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000 (extensible) | |||||
| value | 0..1 | string | Primitive value for code | |||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code | Σ | 1..1 | CodeableConcept | TextResultType Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 (extensible) | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | nl core 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 | 0..1 | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | TextResultDateTime | ||||
| 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 | |||||
| result | 0..* | Reference(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 | nl core TextResult.VisualResult) | Reference to the image source | ||||
| conclusion | 0..1 | string | TextResultReport | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatus | ||||
| DiagnosticReport.status.extension:textResultStatus.value[x] | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000 | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| 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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ZibTextResult
Differential View
This structure is derived from ZibTextResult
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | ZibTextResult | TextResult | |
| subject | 0..1 | Reference(Patient | Group | Device | Location | nl core Patient) | The subject of the report - usually, but not always, the patient | |
| media | ||||
| link | 1..1 | Reference(Media | nl core TextResult.VisualResult) | Reference to the image source | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | ZibTextResult | TextResult | |
| 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 | TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus. |
| textResultStatus | 0..1 | CodeableConcept | Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification | |
| url | 1..1 | uri | "http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification" | |
| code | Σ | 1..1 | CodeableConcept | TextResultType Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 (extensible) |
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | nl core Patient) | The subject of the report - usually, but not always, the patient |
| Slices for effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | TextResultDateTime |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.code | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 |
| 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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | ZibTextResult | TextResult | |||||
| 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): A human language.
| |||||
| 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 | TextResultStatus Binding: DiagnosticReportStatus (required): Use ConceptMap TekstStatusCodelijst_to_DiagnosticReportStatus to translate terminology from the functional model to profile terminology in ValueSet DiagnosticReportStatus. | ||||
| id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| textResultStatus | 0..1 | CodeableConcept | Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| url | 1..1 | uri | "http://nictiz.nl/fhir/StructureDefinition/ext-CodeSpecification" | |||||
| value[x] | 0..1 | CodeableConcept | TextResultStatus Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000 (extensible) | |||||
| value | 0..1 | string | Primitive value for code | |||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| code | Σ | 1..1 | CodeableConcept | TextResultType Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 (extensible) | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | nl core 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 | 0..1 | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | TextResultDateTime | ||||
| 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 | |||||
| result | 0..* | Reference(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 | nl core TextResult.VisualResult) | Reference to the image source | ||||
| conclusion | 0..1 | string | TextResultReport | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DiagnosticReport.language | preferred | CommonLanguages
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatus | ||||
| DiagnosticReport.status.extension:textResultStatus.value[x] | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2--20200901000000 | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
| DiagnosticReport.code | extensible | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1--20200901000000 | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| 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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ZibTextResult
Other representations of profile: CSV, Excel, Schematron