(ร่าง) Thai NCD Implementation Guide
0.1.0 - ci-build
(ร่าง) Thai NCD Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions
Official URL: https://rathpanyowat.github.io/ncd-th-ig-demo/StructureDefinition/ncdth-diagnostic-report-lab | Version: 0.1.0 | |||
Active as of 2022-02-23 | Computable Name: NCDTHDiagnosticReportLab |
ใช้รายงานผลการตรวจแล็บที่มีหลายรายการย่อย (การจัดกลุ่ม Observation เช่น lab panel)
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements (2 nested mandatory elements)
Must-Support: 11 elements
Fixed Value: 3 elements
Slices
This structure defines the following Slices:
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 | |
status | S | 1..1 | code | registered | partial | preliminary | final + Fixed Value: final |
Slices for category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
category:LaboratorySlice | S | 1..1 | CodeableConcept | Service category |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: NCD TH Laboratory Value Set (required) |
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | S | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report |
issued | S | 1..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
result | S | 0..* | Reference(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 | |
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: 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 | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for 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 | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
display | Σ | 0..1 | string | Representation defined by the system |
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: NCD TH Laboratory Value Set (required) |
subject | SΣ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..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 |
encounter | SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 1..1 | instant | DateTime this version was made |
performer | SΣ | 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 | S | 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) | 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): Diagnosis codes provided as adjuncts to the report. | |
presentedForm | 0..* | Attachment | Entire report as issued | |
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 | |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final |
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: NCD TH Laboratory Value Set (required) |
subject | Σ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | Σ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 1..1 | instant | DateTime this version was made |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
result | 0..* | Reference(Observation) | Observations | |
Documentation for this format |
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements (2 nested mandatory elements)
Must-Support: 11 elements
Fixed Value: 3 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
status | S | 1..1 | code | registered | partial | preliminary | final + Fixed Value: final |
Slices for category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
category:LaboratorySlice | S | 1..1 | CodeableConcept | Service category |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: NCD TH Laboratory Value Set (required) |
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | S | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report |
issued | S | 1..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
result | S | 0..* | Reference(Observation) | Observations |
Documentation for this format |
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 | string | 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) Max Binding: AllLanguages: 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 | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for 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 | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB |
display | Σ | 0..1 | string | Representation defined by the system |
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: NCD TH Laboratory Value Set (required) |
subject | SΣ | 1..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..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 |
encounter | SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 1..1 | instant | DateTime this version was made |
performer | SΣ | 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 | S | 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) | 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): Diagnosis codes provided as adjuncts to the report. | |
presentedForm | 0..* | Attachment | Entire report as issued | |
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
DiagnosticReport.status | required | Fixed Value: final |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:LaboratorySlice | example | DiagnosticServiceSectionCodes |
DiagnosticReport.code | required | NCDTHLaboratoryVS |
DiagnosticReport.subject.type | extensible | ResourceType |
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |