Mongolian HDIT Implementation guide
1.0.0 - Review

Mongolian HDIT Implementation guide - Local Development build (v1.0.0). See the Directory of published versions

StructureDefinition: LabReferralMn

A profile used for communicating a request for a diagnostic laboratory service by a medical professional within the same, or another organization. Sending a resource conforming to this profile has a special significance to the HIEP which holds responsibility for finalizing an order with the defined performer of the service.

The official URL for this profile is: 

http://fhir.mn/StructureDefinition/mng-lab-referral

Scope and Usage

Background and Context

Formal Views of Profile Content

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

This structure is derived from ServiceRequest

Summary

Mandatory: 3 elements
Must-Support: 29 elements
Prohibited: 17 elements

Structures

This structure refers to these other structures:

This structure is derived from ServiceRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest 0..*ServiceRequestA request for a service to be performed
... identifier S1..*IdentifierIdentifiers assigned to this order
... instantiatesCanonical S0..0
... instantiatesUri S0..0
... basedOn S0..0
... replaces S0..0
... requisition S0..0
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option
... category S1..*CodeableConceptClassification of service
Binding: LabReferralCategory (required)
... priority S0..1coderoutine | urgent | asap | stat
... doNotPerform S0..0
... orderDetail S0..0
... quantity[x] S0..0
... subject S1..1Reference(PatientMn)Individual or Entity the service is ordered for
... encounter S0..1Reference(Encounter)Encounter in which the request was created
... occurrence[x] S0..0
... asNeeded[x] S0..0
... authoredOn S0..1dateTimeDate request signed
... requester S1..1Reference(PractitionerRoleMn)Who/what is requesting service
... performerType S0..0
... performer S0..*Reference(OrganizationMn)Requested performer
... locationCode S0..0
... locationReference S0..0
... reasonCode S0..*CodeableConceptExplanation/Justification for procedure or service
... insurance S0..0
... supportingInfo S0..0
... specimen S0..*Reference(Specimen)Procedure Samples
... bodySite S0..0
... relevantHistory S0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest I0..*ServiceRequestA request for a service to be performed
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI1..*IdentifierIdentifiers assigned to this order
... status ?!SΣI1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required)
... intent ?!SΣI1..1codeproposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option
Binding: RequestIntent (required)
... category SΣI1..*CodeableConceptClassification of service
Binding: LabReferralCategory (required)
... priority SΣI0..1coderoutine | urgent | asap | stat
Binding: RequestPriority (required)
... code ΣI0..1CodeableConceptWhat is being requested/ordered
Binding: ProcedureCodes(SNOMEDCT) (example)
... subject SΣI1..1Reference(PatientMn)Individual or Entity the service is ordered for
... encounter SΣI0..1Reference(Encounter)Encounter in which the request was created
... authoredOn SΣI0..1dateTimeDate request signed
... requester SΣI1..1Reference(PractitionerRoleMn)Who/what is requesting service
... performer SΣI0..*Reference(OrganizationMn)Requested performer
... reasonCode SΣI0..*CodeableConceptExplanation/Justification for procedure or service
Binding: ProcedureReasonCodes (example)
... reasonReference ΣI0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Explanation/Justification for service or service
... specimen SΣI0..*Reference(Specimen)Procedure Samples
... note I0..*AnnotationComments
... patientInstruction ΣI0..1stringPatient or consumer-oriented instructions

doco Documentation for this format

This structure is derived from ServiceRequest

Summary

Mandatory: 3 elements
Must-Support: 29 elements
Prohibited: 17 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from ServiceRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest 0..*ServiceRequestA request for a service to be performed
... identifier S1..*IdentifierIdentifiers assigned to this order
... instantiatesCanonical S0..0
... instantiatesUri S0..0
... basedOn S0..0
... replaces S0..0
... requisition S0..0
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option
... category S1..*CodeableConceptClassification of service
Binding: LabReferralCategory (required)
... priority S0..1coderoutine | urgent | asap | stat
... doNotPerform S0..0
... orderDetail S0..0
... quantity[x] S0..0
... subject S1..1Reference(PatientMn)Individual or Entity the service is ordered for
... encounter S0..1Reference(Encounter)Encounter in which the request was created
... occurrence[x] S0..0
... asNeeded[x] S0..0
... authoredOn S0..1dateTimeDate request signed
... requester S1..1Reference(PractitionerRoleMn)Who/what is requesting service
... performerType S0..0
... performer S0..*Reference(OrganizationMn)Requested performer
... locationCode S0..0
... locationReference S0..0
... reasonCode S0..*CodeableConceptExplanation/Justification for procedure or service
... insurance S0..0
... supportingInfo S0..0
... specimen S0..*Reference(Specimen)Procedure Samples
... bodySite S0..0
... relevantHistory S0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest I0..*ServiceRequestA request for a service to be performed
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI1..*IdentifierIdentifiers assigned to this order
... status ?!SΣI1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required)
... intent ?!SΣI1..1codeproposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option
Binding: RequestIntent (required)
... category SΣI1..*CodeableConceptClassification of service
Binding: LabReferralCategory (required)
... priority SΣI0..1coderoutine | urgent | asap | stat
Binding: RequestPriority (required)
... code ΣI0..1CodeableConceptWhat is being requested/ordered
Binding: ProcedureCodes(SNOMEDCT) (example)
... subject SΣI1..1Reference(PatientMn)Individual or Entity the service is ordered for
... encounter SΣI0..1Reference(Encounter)Encounter in which the request was created
... authoredOn SΣI0..1dateTimeDate request signed
... requester SΣI1..1Reference(PractitionerRoleMn)Who/what is requesting service
... performer SΣI0..*Reference(OrganizationMn)Requested performer
... reasonCode SΣI0..*CodeableConceptExplanation/Justification for procedure or service
Binding: ProcedureReasonCodes (example)
... reasonReference ΣI0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Explanation/Justification for service or service
... specimen SΣI0..*Reference(Specimen)Procedure Samples
... note I0..*AnnotationComments
... patientInstruction ΣI0..1stringPatient or consumer-oriented instructions

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

Terminology Bindings

PathConformanceValueSet
ServiceRequest.languagepreferredCommonLanguages
Max Binding: AllLanguages
ServiceRequest.statusrequiredRequestStatus
ServiceRequest.intentrequiredRequestIntent
ServiceRequest.categoryrequiredLabCategoryValueSet
ServiceRequest.priorityrequiredRequestPriority
ServiceRequest.codeexampleProcedureCodes(SNOMEDCT)
ServiceRequest.reasonCodeexampleProcedureReasonCodes

Constraints

Constraints

IdPathDetailsRequirements

Overview of laboratory referral scenario

Practitioner (Requester)Practitioner (Requester)EMREMRNationalPatientRegistryNationalPatientRegistryHIEPHIEPPerformer EMRPerformer EMRPractitioner (Performer)Practitioner (Performer)Request patient information1Get Patient2/Patient/?identifier={system}|{code(id)}Add specific searchparameters for differenttypes of identifiers?3Patient4PatientRequest lab test5Register lab request6POST /ServiceRequest/(LabReferralMn)7POST /ServiceRequest/(LabReferralMn)Specimen can be supplied with lab referralif the sample is taken before request is sent.Or added to the LabReport if it is takenby perormer or performers organization.8LabReferralMn9LabReferralMn10ConfirmationReporting of results11Analysis of specimen12Record analysis13POST /DiagnosticReport/(LabReportMn)14POST /DiagnosticReport/(LabReportMn)15Confirmation16(Optional) Notify LabReferralMnidentifier :Identifier[1..*]subject :Reference[1..1] «PatientMn»requester :Reference[1..1] «PractitionerRoleMn»performer :Reference[0..*] «OrganizationMn»category :CodeableConcept![1..1] «ObservationCategoryCodes? »specimen :Reference[0..1] «SpecimenMn» LabReportMnidentifier :Identifier[1..*]basedOn :Reference[1..1] «LabReferralMn»status :code[1..1] «DiagnosticReportStatus!! »category :CodeableConcept![0..*] «LabCategoryValueSet+ »code :CodeableConcept![1..1] «LOINCDiagnosticReportCodes? »subject :Reference[1..1] «PatientMn»encounter :Reference[0..1] «EncounterMn»performer :Reference[0..*] «PractitionerRoleMn»specimen :Reference[0..1] «SpecimenMn»effective[x] : Type [1..1] «dateTime»result :Reference[0..*] «LaboratoryResultMn»conclusion :string[0..1]conclusionCode :CodeableConcept![1..1] «SNOMEDCTClinicalFindings?? » SpecimenMnidentifier :Identifier[1..*]subject :Reference[0..1] «PatientMn»request :Reference[0..1] «LabReferralMn»collection : Collection [0..1]note :Annotation[0..1] LaboratoryResultMnidentifier :Identifier[0..*]basedOn :Reference[0..*] «LabReferralMn»status :code[1..1] «ObservationStatus! »category :CodeableConcept![1..*] «LabCategoryValueSet+ »code :CodeableConcept![1..1] «LOINCCodes! »subject :Reference[1..1] «PatientMn»encounter :Reference[0..1] «EncounterMn»effective[x] : Type [0..1] «dateTime»performer :Reference[0..*] «PractitionerRoleMn»value[x] : Type [1..1] «Quantity|CodeableConcept!|string|boolean|integer|Range|Ratio|SampledData|time|dateTime|Period»interpretation :CodeableConcept![0..*] «AbnormalResultValueSet+ »note :Annotation[0..*]specimen:Reference[0..1] «SpecimenMn»referenceRange: ReferenceRange [0..1]component: Component [0..*] specimen[0..1] basedOn[1..1] result[0..*] specimen[0..1] specimen[0..1]