AU Base Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 4.2.1-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-base/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org.au/fhir/StructureDefinition/au-diagnosticreport | Version: 4.2.1-ci-build | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: AUBaseDiagnosticReport | ||
Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved. |
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This profile defines a diagnostic report structure that localises core concepts, including identifiers and terminology, for use in an Australian context. The purpose of this profile is to provide national level agreement on core localised concepts. This profile does not force conformance to core localised concepts. It enables implementers and modellers to make their own rules, i.e. profiling, about how to support these concepts for specific implementation needs.
Profile specific implementation guidance:
DiagnosticReport.presentedForm.DiagnosticResult.result. Each referenced Observation resource represents an individual diagnostic test and result value or component result values, or a study / panel which references other Observations in Observation.hasMember.Observation.hasMember and not directly referenced in DiagnosticReport.resultDiagnosticReport.code and the study / panel Observation Observation.code should be the same concept if the report contains only the results of that study / panelUsage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |
  identifier | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |
 basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request) | What was requested | |
 category | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
| code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Evaluation Procedure  (preferred) | |
| specimen | 0..* | Reference(AU Base Specimen) | Specimens this report is based on | |
| result | 0..* | Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result) | Observations | |
 conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | |
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | |
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| 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..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |||||
 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 | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Evaluation Procedure (preferred) | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
  effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
 effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| 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(AU Base Specimen) | Specimens this report is based on | |||||
| result | 0..* | Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result) | 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: Clinical Finding (preferred) | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | ||||
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| 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 DiagnosticReport
Summary
Structures
This structure refers to these other structures:
Maturity: 1
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |
| identifier | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request) | What was requested | |
| category | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
| code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Evaluation Procedure (preferred) | |
| specimen | 0..* | Reference(AU Base Specimen) | Specimens this report is based on | |
| result | 0..* | Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result) | Observations | |
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | |
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Key Elements View
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | |
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | |
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| 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..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |||||
| 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 | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request) | What was requested | |||||
| status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: Evaluation Procedure (preferred) | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| 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(AU Base Specimen) | Specimens this report is based on | |||||
| result | 0..* | Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result) | 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: Clinical Finding (preferred) | |||||
| presentedForm | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1from the FHIR Standard | ||||
| DiagnosticReport.category | preferred | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.code | preferred | EvaluationProcedure https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 | ||||
| DiagnosticReport.conclusionCode | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| 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 DiagnosticReport
Summary
Structures
This structure refers to these other structures:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
IG © 2017+ HL7 Australia. Package hl7.fhir.au.base#4.2.1-ci-build based on FHIR 4.0.1. Generated 2024-03-17
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