Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft Australia flag

Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions

Resource Profile: ADHA Core DiagnosticReport

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-diagnosticreport-core-1 Version: 0.2.3
Draft as of 2024-09-12 Computable Name: ADHADiagnosticReportCore

Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to define a core representation of a diagnostic report issued by the diagnostic service provider to support the electronic exchange of the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile is intended to be capable of supporting reporting for specialist and other diagnostic disciplines that are not pathology or imaging.

This profile identifies the additional constraints, extensions, and value sets that build on and extend DiagnosticReport that are supported.

Where a more specific DiagnosticReport profile is applicable, e.g. pathology report or imaging report, an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set a core DiagnosticReport standard for:

  • Query for diagnostic reports for a patient
  • Record or update diagnostic reports belonging to a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

  • DiagnosticReport.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • Results that are free text or report form are represented using ‘DiagnosticReport.presentedForm`.
  • References to a Media resource are preferred to be contained but may be an external resource.
  • The DiagnosticReport resource can represent the clinical conclusion as a text summary with DiagnosticReport.conclusion or a set of codes with DiagnosticReport.conclusionCode.
    • Although both are marked as must support, sending systems are not required to support both a text and a set of codes, but they SHALL support at least one of these elements.
    • A receiving or persisting system SHALL support both elements.
  • The DiagnosticReport resource can represent the result as a text summary with DiagnosticReport.conclusion or a set of codes with DiagnosticReport.conclusionCode.
    • Although both are marked as must support, sending systems are not required to support both a text and a set of codes, but they SHALL support at least one of these elements.
    • A receiving or persisting system SHALL support both elements.

Boundaries and relationships

These profiles build on this profile (ADHA Core DiagnosticReport) to define specific roles:

Usage:

Formal Views of Profile Content

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

This structure is derived from AUBaseDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... identifier S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn S 0..* Reference(ADHA Core ServiceRequest) Diagnostic investigation order
... status S 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... code S 1..1 CodeableConcept Diagnostic examination name / study name / group name
... subject SC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... effective[x] SC 1..1 dateTime, Period Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
... issued S 1..1 instant Diagnostic report date time
... performer SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... media S 0..* BackboneElement Key images associated with this report
.... link 1..1 Reference(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... status ?!SΣ 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... category SΣ 1..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ 1..1 CodeableConcept Diagnostic examination name / study name / group name
Binding: Evaluation Procedure . (preferred)
... subject SΣC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... effective[x] SΣC 1..1 Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant Diagnostic report date time
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... media SΣ 0..* BackboneElement Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link Σ 1..1 Reference(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: Clinical Finding . (preferred)
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredEvaluationProcedure .
https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... 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
... 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 S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn S 0..* Reference(ADHA Core ServiceRequest) Diagnostic investigation order
... status ?!SΣ 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... category SΣ 1..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ 1..1 CodeableConcept Diagnostic examination name / study name / group name
Binding: Evaluation Procedure . (preferred)
... subject SΣC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 1..1 Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant Diagnostic report date time
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..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
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 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(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: Clinical Finding . (preferred)
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredEvaluationProcedure .
https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.result.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Differential View

This structure is derived from AUBaseDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... identifier S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn S 0..* Reference(ADHA Core ServiceRequest) Diagnostic investigation order
... status S 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... code S 1..1 CodeableConcept Diagnostic examination name / study name / group name
... subject SC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... effective[x] SC 1..1 dateTime, Period Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
... issued S 1..1 instant Diagnostic report date time
... performer SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... media S 0..* BackboneElement Key images associated with this report
.... link 1..1 Reference(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... status ?!SΣ 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... category SΣ 1..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ 1..1 CodeableConcept Diagnostic examination name / study name / group name
Binding: Evaluation Procedure . (preferred)
... subject SΣC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... effective[x] SΣC 1..1 Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant Diagnostic report date time
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... media SΣ 0..* BackboneElement Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link Σ 1..1 Reference(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: Clinical Finding . (preferred)
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredEvaluationProcedure .
https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* AUBaseDiagnosticReport A diagnostic report in an Australian healthcare context
inv-dh-dir-01: The report shall at least have a result or a presentedForm
... 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
... 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 S 1..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn S 0..* Reference(ADHA Core ServiceRequest) Diagnostic investigation order
... status ?!SΣ 1..1 code partial | preliminary | final +
Binding: DiagnosticReportStatus Report Available . (required)
... category SΣ 1..* CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ 1..1 CodeableConcept Diagnostic examination name / study name / group name
Binding: Evaluation Procedure . (preferred)
... subject SΣC 1..1 Reference(ADHA Core Patient) The subject of the report - usually, but not always, the patient
inv-dh-dir-02: At least reference or a valid identifier shall be present
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 1..1 Clinically relevant time/time-period for report
inv-dh-dir-04: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 1..1 instant Diagnostic report date time
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization) Responsible Diagnostic Service
inv-dh-dir-03: At least reference or a valid identifier shall be present
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result SC 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Observations
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..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
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 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(ADHA Core Media) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: Clinical Finding . (preferred)
... presentedForm SC 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatusReportAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredEvaluationProcedure .
https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.result.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
inv-dh-dir-02errorDiagnosticReport.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-03errorDiagnosticReport.performerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
identifier token SHALL An identifier for the report DiagnosticReport.identifier
category token SHALL Which diagnostic discipline/department created the report DiagnosticReport.category
subject:identifier token SHALL The subject of the report if a patient DiagnosticReport.subject.identifier
code token SHALL 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
date date SHALL The clinically relevant time of the report DiagnosticReport.effective
status token SHOULD The status of the report DiagnosticReport.status

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all diagnostic reports for a patient using the subject:identifier search parameter:

    GET [base]/DiagnosticReport?subject:identifier={system|}[code]

    Example:

     GET [base]/DiagnosticReport?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient (how to search by :identifier)

  2. SHALL support searching using the identifier search parameter:

    GET [base]/DiagnosticReport?identifier={system|}[code]

    Example:

     GET [base]/DiagnosticReport?identifier=http://doombenpathlabs.example.com/reports|1032702

    Implementation Notes: Fetches a bundle containing any DiagnosticReport resources matching the identifier (how to search by token)

  3. SHALL support searching using the combination subject:identifier and category search parameter:

    GET [base]/DiagnosticReport?subject:identifier={system|}[code]&category[code]

    Example:

     GET [base]/DiagnosticReport?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&category=http://terminology.hl7.org/CodeSystem/v2-0074|AU

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources with the category of "Audiology" for the specified patient (how to search by :identifier and how to search by token)

  4. SHALL support searching using the combination subject:identifier and code search parameter:

    GET [base]/DiagnosticReport?subject:identifier={system|}[code]&code={system|}[code]

    Example:

     GET [base]/DiagnosticReport?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&code=http://loinc.org|68635-2

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources with the code of an 68635-2 (Audiology Diagnostic study note) for the specified patient (how to search by :identifier and how to search by token)

  5. SHALL support searching using the combination of the subject:identifier and date search parameters:

    GET [base]/DiagnosticReport?subject:identifier={system|}[code]&date=[date]

    Example:

     GET [base]/DiagnosticReport?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&date=ge2013-03-14

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient that have a date greater than or equal to 21st Jan 2013. (how to search by :identifier and how to search by date)