Orders
and
Observations
![]() | Maturity Level : 3 | Trial Use | Security Category : Patient | Compartments : Device , Encounter , Patient , Practitioner |
The
findings
and
interpretation
of
diagnostic
tests
performed
on
patients,
groups
of
patients,
products,
substances,
devices,
and
locations,
and/or
specimens
derived
from
these.
The
report
includes
clinical
context
such
as
requesting
and
provider
information,
and
some
mix
of
atomic
results,
images,
textual
and
coded
interpretations,
and
formatted
representation
of
diagnostic
reports.
The
report
also
includes
non-clinical
context
such
as
batch
analysis
and
stability
reporting
of
products
and
substances.
This resource is an event resource from a FHIR workflow perspective - see Workflow . It is the intent of the Orders and Observation Workgroup to align this resource with the workflow pattern for event resources .
A diagnostic report is the set of information that is typically provided by a diagnostic service when investigations are complete. The information includes a mix of atomic results, text reports, images, and codes. The mix varies depending on the nature of the diagnostic procedure, and sometimes on the nature of the outcomes for a particular investigation. In FHIR, the report can be conveyed in a variety of ways including a Document , RESTful API , or Messaging framework. Included within each of these, would be the DiagnosticReport resource itself.
The DiagnosticReport resource has information about the diagnostic report itself, and about the subject and, in the case of laboratory tests, the specimen of the report. It can also refer to the request details and atomic observations details or image instances. Report conclusions can be expressed as a simple text blob, structured coded data or as an attached fully formatted report such as a PDF.
The DiagnosticReport resource is suitable for the following kinds of diagnostic reports:
The DiagnosticReport resource is not intended to support cumulative result presentation (tabular presentation of past and present results in the resource). The DiagnosticReport resource does not yet provide full support for detailed structured reports of sequencing; this is planned for a future release.
The words "tests", "results", "observations", "panels" and "batteries" are often used interchangeably when describing the various parts of a diagnostic report. This leads to much confusion. The naming confusion is worsened because of the wide variety of forms that the result of a diagnostic investigation can take, as described above. Languages other than English have their own variations on this theme.
This resource uses one particular set of terms. A practitioner "requests" a set of "tests". The diagnostic service returns a "report" which may contain a "narrative" - a written summary of the outcomes, and/or "results" - the individual pieces of atomic data which each are "observations". The results are assembled in "groups" which are nested structures of Observations (traditionally referred to as "panels" or " batteries" by laboratories) that can be used to represent relationships between the individual data items.
Note that many diagnostic processes are procedures that generate observations and diagnostic reports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the Procedure resource is used to describe the activity.
In contrast to the Observation resource, the DiagnosticReport resource typically includes additional clinical context and some mix of atomic results, images, imaging reports, textual and coded interpretation, and formatted representations. Laboratory reports, pathology reports, and imaging reports should be represented using the DiagnosticReport resource. The Observation resource is referenced by the DiagnosticReport to provide the atomic results for a particular investigation.
If you have a highly structured report, then use DiagnosticReport - it has data and workflow support. Details about the request for a diagnostic investigation are captured in the various "request" resources (e.g., the ServiceRequest ) and allow the report to connect to clinical workflows. For more narrative driven reports with less work flow (histology/mortuary, etc.), the Composition resource would be more appropriate.
Image and media representations of the report and supporting images are referenced in the DiagnosticReport resource. The details and actual image instances can be referenced directly in Diagnostic report using the "imaging" element or by indirect reference through the ImagingStudy resources which represent the content produced in a DICOM imaging study or set of DICOM Instances for a patient.
This
resource
is
referenced
by
CarePlan
,
ChargeItem
,
ClinicalImpression
,
Communication
,
CommunicationRequest
,
Condition
,
Contract
,
DeviceRequest
,
DeviceUseStatement
,
FamilyMemberHistory
,
GuidanceResponse
,
ImagingStudy
,
Immunization
,
MedicationAdministration
,
MedicationStatement
,
Procedure
,
RequestGroup
,
RiskAssessment
,
ServiceRequest
and
SupplyRequest
Procedure
.
This resource implements the Event pattern.
Structure
Name | Flags | Card. | Type |
Description
&
Constraints
![]() |
---|---|---|---|---|
![]() ![]() | TU | DomainResource |
A
Diagnostic
report
-
a
combination
of
request
information,
atomic
results,
images,
interpretation,
as
well
as
formatted
reports
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension | |
![]() ![]() ![]() | Σ | 0..* | Identifier |
Business
identifier
for
report
|
![]() ![]() ![]() | 0..* | Reference ( CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest ) |
What
was
requested
| |
![]() ![]() ![]() | ?! Σ | 1..1 | code |
registered
|
partial
|
preliminary
|
final
+
DiagnosticReportStatus ( Required ) |
![]() ![]() ![]() | Σ | 0..* | CodeableConcept |
Service
category
Diagnostic Service Section Codes ( Example ) |
![]() ![]() ![]() | Σ | 1..1 | CodeableConcept |
Name/Code
for
this
diagnostic
report
LOINC Diagnostic Report Codes ( Preferred ) |
![]() ![]() ![]() | Σ | 0..1 | Reference ( Patient | Group | Device | Location | Medication | Substance ) | The subject of the report - usually, but not always, the patient |
![]() ![]() ![]() | Σ | 0..1 | Reference ( Encounter ) | Health care event when test ordered |
![]() ![]() ![]() | Σ | 0..1 | Clinically relevant time/time-period for report | |
![]() ![]() ![]() ![]() | dateTime | |||
![]() ![]() ![]() ![]() | Period | |||
![]() ![]() ![]() | Σ | 0..1 | instant | DateTime this version was made |
![]() ![]() ![]() | Σ | 0..* | Reference ( Practitioner | PractitionerRole | Organization | CareTeam ) |
Responsible
Diagnostic
Service
|
![]() ![]() ![]() | Σ | 0..* | Reference ( Practitioner | PractitionerRole | Organization | CareTeam ) |
Primary
result
interpreter
|
![]() ![]() ![]() | 0..* | Reference ( Specimen ) |
Specimens
this
report
is
based
on
| |
![]() ![]() ![]() | 0..* | Reference ( Observation ) |
Observations
| |
![]() ![]() ![]() | 0..* | Reference ( ImagingStudy ) |
Reference
to
full
details
of
imaging
associated
with
the
diagnostic
report
| |
![]() ![]() ![]() | Σ | 0..* | BackboneElement |
Key
images
associated
with
this
report
|
![]() ![]() ![]() ![]() | 0..1 | string | Comment about the image (e.g. explanation) | |
![]() ![]() ![]() ![]() | Σ | 1..1 |
Reference
(
| Reference to the image source |
![]() ![]() ![]() | 0..1 | string | Clinical conclusion (interpretation) of test results | |
![]() ![]() ![]() | 0..* | CodeableConcept |
Codes
for
the
clinical
conclusion
of
test
results
SNOMED CT Clinical Findings ( Example ) | |
![]() ![]() ![]() | 0..* | Attachment |
Entire
report
as
issued
| |
![]() |
UML Diagram ( Legend )
XML Template
<DiagnosticReport xmlns="http://hl7.org/fhir"><!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business identifier for report --></identifier> <basedOn><!-- 0..* Reference(CarePlan|ImmunizationRecommendation| MedicationRequest|NutritionOrder|ServiceRequest) What was requested --></basedOn> <status value="[code]"/><!-- 1..1 registered | partial | preliminary | final + --> <category><!-- 0..* CodeableConcept Service category --></category> <code><!-- 1..1 CodeableConcept Name/Code for this diagnostic report --></code>
<</subject><subject><!-- 0..1 Reference(Device|Group|Location|Medication|Patient|Substance) The subject of the report - usually, but not always, the patient --></subject> <encounter><!-- 0..1 Reference(Encounter) Health care event when test ordered --></encounter> <effective[x]><!-- 0..1 dateTime|Period Clinically relevant time/time-period for report --></effective[x]> <issued value="[instant]"/><!-- 0..1 DateTime this version was made --><| </performer> <| </resultsInterpreter><performer><!-- 0..* Reference(CareTeam|Organization|Practitioner| PractitionerRole) Responsible Diagnostic Service --></performer> <resultsInterpreter><!-- 0..* Reference(CareTeam|Organization|Practitioner| PractitionerRole) Primary result interpreter --></resultsInterpreter> <specimen><!-- 0..* Reference(Specimen) Specimens this report is based on --></specimen> <result><!-- 0..* Reference(Observation) Observations --></result> <imagingStudy><!-- 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report --></imagingStudy> <media> <!-- 0..* Key images associated with this report --> <comment value="[string]"/><!-- 0..1 Comment about the image (e.g. explanation) --><</link><link><!-- 1..1 Reference(DocumentReference) Reference to the image source --></link> </media> <conclusion value="[string]"/><!-- 0..1 Clinical conclusion (interpretation) of test results --> <conclusionCode><!-- 0..* CodeableConcept Codes for the clinical conclusion of test results --></conclusionCode> <presentedForm><!-- 0..* Attachment Entire report as issued --></presentedForm> </DiagnosticReport>
JSON Template
{![]()
"resourceType" : "","resourceType" : "DiagnosticReport", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifier for report "basedOn" : [{ Reference(CarePlan|ImmunizationRecommendation| MedicationRequest|NutritionOrder|ServiceRequest) }], // What was requested "status" : "<code>", // R! registered | partial | preliminary | final + "category" : [{ CodeableConcept }], // Service category "code" : { CodeableConcept }, // R! Name/Code for this diagnostic report""subject" : { Reference(Device|Group|Location|Medication|Patient|Substance) }, // The subject of the report - usually, but not always, the patient "encounter" : { Reference(Encounter) }, // Health care event when test ordered // effective[x]: Clinically relevant time/time-period for report. One of these 2: "effectiveDateTime" : "<dateTime>", "effectivePeriod" : { Period }, "issued" : "<instant>", // DateTime this version was made"| "|"performer" : [{ Reference(CareTeam|Organization|Practitioner| PractitionerRole) }], // Responsible Diagnostic Service "resultsInterpreter" : [{ Reference(CareTeam|Organization|Practitioner| PractitionerRole) }], // Primary result interpreter "specimen" : [{ Reference(Specimen) }], // Specimens this report is based on "result" : [{ Reference(Observation) }], // Observations "imagingStudy" : [{ Reference(ImagingStudy) }], // Reference to full details of imaging associated with the diagnostic report "media" : [{ // Key images associated with this report "comment" : "<string>", // Comment about the image (e.g. explanation)""link" : { Reference(DocumentReference) } // R! Reference to the image source }], "conclusion" : "<string>", // Clinical conclusion (interpretation) of test results "conclusionCode" : [{ CodeableConcept }], // Codes for the clinical conclusion of test results "presentedForm" : [{ Attachment }] // Entire report as issued }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .![]()
[ a fhir:;[ a fhir:DiagnosticReport; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:DiagnosticReport.identifier [ Identifier ], ... ; # 0..* Business identifier for report fhir:DiagnosticReport.basedOn [ Reference(CarePlan|ImmunizationRecommendation|MedicationRequest|NutritionOrder| ServiceRequest) ], ... ; # 0..* What was requested fhir:DiagnosticReport.status [ code ]; # 1..1 registered | partial | preliminary | final + fhir:DiagnosticReport.category [ CodeableConcept ], ... ; # 0..* Service category fhir:DiagnosticReport.code [ CodeableConcept ]; # 1..1 Name/Code for this diagnostic reportfhir:fhir:DiagnosticReport.subject [ Reference(Device|Group|Location|Medication|Patient|Substance) ]; # 0..1 The subject of the report - usually, but not always, the patient fhir:DiagnosticReport.encounter [ Reference(Encounter) ]; # 0..1 Health care event when test ordered # DiagnosticReport.effective[x] : 0..1 Clinically relevant time/time-period for report. One of these 2 fhir:DiagnosticReport.effectiveDateTime [ dateTime ] fhir:DiagnosticReport.effectivePeriod [ Period ] fhir:DiagnosticReport.issued [ instant ]; # 0..1 DateTime this version was madefhir: fhir:fhir:DiagnosticReport.performer [ Reference(CareTeam|Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Responsible Diagnostic Service fhir:DiagnosticReport.resultsInterpreter [ Reference(CareTeam|Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Primary result interpreter fhir:DiagnosticReport.specimen [ Reference(Specimen) ], ... ; # 0..* Specimens this report is based on fhir:DiagnosticReport.result [ Reference(Observation) ], ... ; # 0..* Observations fhir:DiagnosticReport.imagingStudy [ Reference(ImagingStudy) ], ... ; # 0..* Reference to full details of imaging associated with the diagnostic report fhir:DiagnosticReport.media [ # 0..* Key images associated with this report fhir:DiagnosticReport.media.comment [ string ]; # 0..1 Comment about the image (e.g. explanation)fhir:fhir:DiagnosticReport.media.link [ Reference(DocumentReference) ]; # 1..1 Reference to the image source ], ...; fhir:DiagnosticReport.conclusion [ string ]; # 0..1 Clinical conclusion (interpretation) of test results fhir:DiagnosticReport.conclusionCode [ CodeableConcept ], ... ; # 0..* Codes for the clinical conclusion of test results fhir:DiagnosticReport.presentedForm [ Attachment ], ... ; # 0..* Entire report as issued ]
Changes since R3
DiagnosticReport | |
|
|
|
|
|
|
See the Full Difference for further information
This analysis is available as XML or JSON .
See R3 <--> R4 Conversion Maps (status = 14 tests that all execute ok. All tests pass round-trip testing and 9 r3 resources are invalid (0 errors). )
Structure
Name | Flags | Card. | Type |
Description
&
Constraints
![]() |
---|---|---|---|---|
![]() ![]() | TU | DomainResource |
A
Diagnostic
report
-
a
combination
of
request
information,
atomic
results,
images,
interpretation,
as
well
as
formatted
reports
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension | |
![]() ![]() ![]() | Σ | 0..* | Identifier |
Business
identifier
for
report
|
![]() ![]() ![]() | 0..* | Reference ( CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest ) |
What
was
requested
| |
![]() ![]() ![]() | ?! Σ | 1..1 | code |
registered
|
partial
|
preliminary
|
final
+
DiagnosticReportStatus ( Required ) |
![]() ![]() ![]() | Σ | 0..* | CodeableConcept |
Service
category
Diagnostic Service Section Codes ( Example ) |
![]() ![]() ![]() | Σ | 1..1 | CodeableConcept |
Name/Code
for
this
diagnostic
report
LOINC Diagnostic Report Codes ( Preferred ) |
![]() ![]() ![]() | Σ | 0..1 | Reference ( Patient | Group | Device | Location | Medication | Substance ) | The subject of the report - usually, but not always, the patient |
![]() ![]() ![]() | Σ | 0..1 | Reference ( Encounter ) | Health care event when test ordered |
![]() ![]() ![]() | Σ | 0..1 | Clinically relevant time/time-period for report | |
![]() ![]() ![]() ![]() | dateTime | |||
![]() ![]() ![]() ![]() | Period | |||
![]() ![]() ![]() | Σ | 0..1 | instant | DateTime this version was made |
![]() ![]() ![]() | Σ | 0..* | Reference ( Practitioner | PractitionerRole | Organization | CareTeam ) |
Responsible
Diagnostic
Service
|
![]() ![]() ![]() | Σ | 0..* | Reference ( Practitioner | PractitionerRole | Organization | CareTeam ) |
Primary
result
interpreter
|
![]() ![]() ![]() | 0..* | Reference ( Specimen ) |
Specimens
this
report
is
based
on
| |
![]() ![]() ![]() | 0..* | Reference ( Observation ) |
Observations
| |
![]() ![]() ![]() | 0..* | Reference ( ImagingStudy ) |
Reference
to
full
details
of
imaging
associated
with
the
diagnostic
report
| |
![]() ![]() ![]() | Σ | 0..* | BackboneElement |
Key
images
associated
with
this
report
|
![]() ![]() ![]() ![]() | 0..1 | string | Comment about the image (e.g. explanation) | |
![]() ![]() ![]() ![]() | Σ | 1..1 |
Reference
(
| Reference to the image source |
![]() ![]() ![]() | 0..1 | string | Clinical conclusion (interpretation) of test results | |
![]() ![]() ![]() | 0..* | CodeableConcept |
Codes
for
the
clinical
conclusion
of
test
results
SNOMED CT Clinical Findings ( Example ) | |
![]() ![]() ![]() | 0..* | Attachment |
Entire
report
as
issued
| |
![]() |
XML Template
<DiagnosticReport xmlns="http://hl7.org/fhir"><!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business identifier for report --></identifier> <basedOn><!-- 0..* Reference(CarePlan|ImmunizationRecommendation| MedicationRequest|NutritionOrder|ServiceRequest) What was requested --></basedOn> <status value="[code]"/><!-- 1..1 registered | partial | preliminary | final + --> <category><!-- 0..* CodeableConcept Service category --></category> <code><!-- 1..1 CodeableConcept Name/Code for this diagnostic report --></code>
<</subject><subject><!-- 0..1 Reference(Device|Group|Location|Medication|Patient|Substance) The subject of the report - usually, but not always, the patient --></subject> <encounter><!-- 0..1 Reference(Encounter) Health care event when test ordered --></encounter> <effective[x]><!-- 0..1 dateTime|Period Clinically relevant time/time-period for report --></effective[x]> <issued value="[instant]"/><!-- 0..1 DateTime this version was made --><| </performer> <| </resultsInterpreter><performer><!-- 0..* Reference(CareTeam|Organization|Practitioner| PractitionerRole) Responsible Diagnostic Service --></performer> <resultsInterpreter><!-- 0..* Reference(CareTeam|Organization|Practitioner| PractitionerRole) Primary result interpreter --></resultsInterpreter> <specimen><!-- 0..* Reference(Specimen) Specimens this report is based on --></specimen> <result><!-- 0..* Reference(Observation) Observations --></result> <imagingStudy><!-- 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report --></imagingStudy> <media> <!-- 0..* Key images associated with this report --> <comment value="[string]"/><!-- 0..1 Comment about the image (e.g. explanation) --><</link><link><!-- 1..1 Reference(DocumentReference) Reference to the image source --></link> </media> <conclusion value="[string]"/><!-- 0..1 Clinical conclusion (interpretation) of test results --> <conclusionCode><!-- 0..* CodeableConcept Codes for the clinical conclusion of test results --></conclusionCode> <presentedForm><!-- 0..* Attachment Entire report as issued --></presentedForm> </DiagnosticReport>
JSON Template
{![]()
"resourceType" : "","resourceType" : "DiagnosticReport", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifier for report "basedOn" : [{ Reference(CarePlan|ImmunizationRecommendation| MedicationRequest|NutritionOrder|ServiceRequest) }], // What was requested "status" : "<code>", // R! registered | partial | preliminary | final + "category" : [{ CodeableConcept }], // Service category "code" : { CodeableConcept }, // R! Name/Code for this diagnostic report""subject" : { Reference(Device|Group|Location|Medication|Patient|Substance) }, // The subject of the report - usually, but not always, the patient "encounter" : { Reference(Encounter) }, // Health care event when test ordered // effective[x]: Clinically relevant time/time-period for report. One of these 2: "effectiveDateTime" : "<dateTime>", "effectivePeriod" : { Period }, "issued" : "<instant>", // DateTime this version was made"| "|"performer" : [{ Reference(CareTeam|Organization|Practitioner| PractitionerRole) }], // Responsible Diagnostic Service "resultsInterpreter" : [{ Reference(CareTeam|Organization|Practitioner| PractitionerRole) }], // Primary result interpreter "specimen" : [{ Reference(Specimen) }], // Specimens this report is based on "result" : [{ Reference(Observation) }], // Observations "imagingStudy" : [{ Reference(ImagingStudy) }], // Reference to full details of imaging associated with the diagnostic report "media" : [{ // Key images associated with this report "comment" : "<string>", // Comment about the image (e.g. explanation)""link" : { Reference(DocumentReference) } // R! Reference to the image source }], "conclusion" : "<string>", // Clinical conclusion (interpretation) of test results "conclusionCode" : [{ CodeableConcept }], // Codes for the clinical conclusion of test results "presentedForm" : [{ Attachment }] // Entire report as issued }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .![]()
[ a fhir:;[ a fhir:DiagnosticReport; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:DiagnosticReport.identifier [ Identifier ], ... ; # 0..* Business identifier for report fhir:DiagnosticReport.basedOn [ Reference(CarePlan|ImmunizationRecommendation|MedicationRequest|NutritionOrder| ServiceRequest) ], ... ; # 0..* What was requested fhir:DiagnosticReport.status [ code ]; # 1..1 registered | partial | preliminary | final + fhir:DiagnosticReport.category [ CodeableConcept ], ... ; # 0..* Service category fhir:DiagnosticReport.code [ CodeableConcept ]; # 1..1 Name/Code for this diagnostic reportfhir:fhir:DiagnosticReport.subject [ Reference(Device|Group|Location|Medication|Patient|Substance) ]; # 0..1 The subject of the report - usually, but not always, the patient fhir:DiagnosticReport.encounter [ Reference(Encounter) ]; # 0..1 Health care event when test ordered # DiagnosticReport.effective[x] : 0..1 Clinically relevant time/time-period for report. One of these 2 fhir:DiagnosticReport.effectiveDateTime [ dateTime ] fhir:DiagnosticReport.effectivePeriod [ Period ] fhir:DiagnosticReport.issued [ instant ]; # 0..1 DateTime this version was madefhir: fhir:fhir:DiagnosticReport.performer [ Reference(CareTeam|Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Responsible Diagnostic Service fhir:DiagnosticReport.resultsInterpreter [ Reference(CareTeam|Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Primary result interpreter fhir:DiagnosticReport.specimen [ Reference(Specimen) ], ... ; # 0..* Specimens this report is based on fhir:DiagnosticReport.result [ Reference(Observation) ], ... ; # 0..* Observations fhir:DiagnosticReport.imagingStudy [ Reference(ImagingStudy) ], ... ; # 0..* Reference to full details of imaging associated with the diagnostic report fhir:DiagnosticReport.media [ # 0..* Key images associated with this report fhir:DiagnosticReport.media.comment [ string ]; # 0..1 Comment about the image (e.g. explanation)fhir:fhir:DiagnosticReport.media.link [ Reference(DocumentReference) ]; # 1..1 Reference to the image source ], ...; fhir:DiagnosticReport.conclusion [ string ]; # 0..1 Clinical conclusion (interpretation) of test results fhir:DiagnosticReport.conclusionCode [ CodeableConcept ], ... ; # 0..* Codes for the clinical conclusion of test results fhir:DiagnosticReport.presentedForm [ Attachment ], ... ; # 0..* Entire report as issued ]
Changes since Release 3
DiagnosticReport | |
|
|
|
|
|
|
See the Full Difference for further information
This analysis is available as XML or JSON .
See R3 <--> R4 Conversion Maps (status = 14 tests that all execute ok. All tests pass round-trip testing and 9 r3 resources are invalid (0 errors). )
See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a
Path | Definition | Type | Reference |
---|---|---|---|
DiagnosticReport.status | The status of the diagnostic report. | Required | DiagnosticReportStatus |
DiagnosticReport.category | Codes for diagnostic service sections. | Example | DiagnosticServiceSectionCodes |
DiagnosticReport.code | Codes that describe Diagnostic Reports. | Preferred | LOINCDiagnosticReportCodes |
DiagnosticReport.conclusionCode | Diagnosis codes provided as adjuncts to the report. | Example | SNOMEDCTClinicalFindings |
type
element
that
may
be
used
to
distinguish
the
identifiers
assigned
by
the
requester
and
the
performer
of
the
request
(known
as
the
'Placer'
and
'Filler'
in
the
HL7
Version
2
Messaging
Standard).
Use
the
identifier
type
code
"PLAC"
for
the
Placer
Identifier
and
"FILL"
for
the
Filler
identifier
as
is
shown
in
the
example
below:
<!-- Placer identifier--> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="PLAC"/> </coding> <text value="Placer"/> </type> <system value="urn:oid:1.3.4.5.6.7"/> <value value="2345234234234"/> </identifier> <!-- Filler identifier--> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="PLAC"/> </coding> <text value="Placer"/> </type> <system value=" http://terminology.hl7.org/CodeSystem/v2-0203"/> <value value="567890"/> </identifier>
If
the
diagnostic
procedure
was
performed
on
the
patient
directly,
the
effective[x]
element
is
a
dateTime,
the
time
it
was
performed.
If
specimens
were
taken,
the
clinically
relevant
time
of
the
report
can
be
derived
from
the
specimen
collection
times,
but
since
detailed
specimen
information
is
not
always
available,
and
nor
is
the
clinically
relevant
time
always
exactly
the
specimen
collection
time
(e.g.
complex
timed
tests),
the
reports
SHALL
always
include
an
effective[x]
element.
Note
that
HL7
v2
messages
often
carry
a
diagnostically
relevant
time
without
carrying
any
specimen
information.
ImagingStudy
and
ImageObjectStudy
and
the
media
element
are
somewhat
overlapping
-
typically,
the
list
of
image
references
in
the
image
element
will
also
be
found
in
one
of
the
imaging
study
resources.
However,
each
caters
to
different
types
of
displays
for
different
types
of
purposes.
Neither,
either,
or
both
may
be
provided.
Typically, a report is either: all data, no narrative (e.g. Core lab) or a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density), or all narrative (for example a typical imaging report, histopathology). This resource provides for these 3 different presentations:
Note that the conclusion and the coded diagnoses are part of the atomic data and SHOULD be duplicated in the narrative and in the presented form if the latter is present. The narrative and the presented form serve the same function: a representation of the report for a human. The presented form is included since diagnostic service reports often contain presentation features that are not easy to reproduce in the HTML narrative. Whether or not the presented form is included, the narrative must be a clinically safe view of the diagnostic report; at a minimum, this could be fulfilled by a note indicating that the narrative is not proper representation of the report, and that the presented form must be used, or a generated view from the atomic data. However, consumers of the report will best be served if the narrative contains clinically relevant data from the form. Commonly, the following patterns are used:
Note that the nature of reports from the various disciplines that provide diagnostic reports are changing quickly, as expert systems provide improved narrative reporting in high volume reports, structured reporting brings additional data to areas that have classically been narrative based, and the nature of the imaging and laboratory procedures are merging. Therefore, these patterns described above are only examples of how a diagnostic report can be used.
Genetic
reporting
makes
heavy
use
of
the
DiagnosticReport
and
Observation
resources.
An
implementation
guide
describing
how
to
represent
genetic
results
can
be
found
here
.
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
based-on | reference | Reference to the service request. |
DiagnosticReport.basedOn
( CarePlan , MedicationRequest , NutritionOrder , ServiceRequest , ImmunizationRecommendation ) | |
category | token | Which diagnostic discipline/department created the report | DiagnosticReport.category | |
code | token | The code for the report, as opposed to codes for the atomic results, which are the names on the observation resource referred to from the result | DiagnosticReport.code |
|
conclusion | token | A coded conclusion (interpretation/impression) on the report | DiagnosticReport.conclusionCode | |
date | date | The clinically relevant time of the report | DiagnosticReport.effective |
|
encounter | reference | The Encounter when the order was made |
DiagnosticReport.encounter
( Encounter ) |
|
identifier | token | An identifier for the report | DiagnosticReport.identifier |
|
issued N | date | When the report was issued | DiagnosticReport.issued | |
media | reference | A reference to the image source. |
DiagnosticReport.media.link
( | |
patient | reference | The subject of the report if a patient |
DiagnosticReport.subject.where(resolve()
is
Patient)
( Group , Device , Medication , Patient , Substance , Location ) |
|
performer | reference | Who is responsible for the report |
DiagnosticReport.performer
( Practitioner , Organization , CareTeam , PractitionerRole ) | |
result | reference | Link to an atomic result (observation resource) |
DiagnosticReport.result
( Observation ) | |
results-interpreter | reference | Who was the source of the report |
DiagnosticReport.resultsInterpreter
( Practitioner , Organization , CareTeam , PractitionerRole ) | |
specimen | reference | The specimen details |
DiagnosticReport.specimen
( Specimen ) | |
status N | token | The status of the report | DiagnosticReport.status | |
subject | reference | The subject of the report |
DiagnosticReport.subject
( Group , Device , Medication , Patient , Substance , Location ) |