AU Base Implementation Guide
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AU Base Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 6.0.0-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

Resource Profile: AU Base DiagnosticReport

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-diagnosticreport Version: 6.0.0-ci-build
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBaseDiagnosticReport

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

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.

For specific reporting of pathology or imaging services the more specific AU Base Pathology Report or AU Base Diagnostic Imaging Report profiles would be preferred. This profile is suitable for any other diagnostic service reporting needs.

Usage Notes

Profile specific implementation guidance:

  • Results that are free text or report form are represented in DiagnosticReport.presentedForm.
  • Results that are structured in FHIR resources are referenced in 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.
  • When constructing a report for a study / panel:
    • the individual component examinations are referenced by that grouping Observation in Observation.hasMember and not directly referenced in DiagnosticReport.result
    • DiagnosticReport.code and the study / panel Observation Observation.code should be the same concept if the report contains only the results of that study / panel
  • See each Identifier profile page for guidance related to that identifier type.
  • For guidance on representing a pathology report issued by the diagnostic service provider, the AU Base Pathology Report profile is preferred.
  • For guidance on representing an imaging report issued by the diagnostic service provider, the AU Base Diagnostic Imaging Report profile is preferred.

Usages:

Changes since version 5.0.0:

  • The resource metadata has changed (title)

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DiagnosticReport 0..* DiagnosticReport A diagnostic report in an Australian healthcare context
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... 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)
    ... 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)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
    From the FHIR Standard
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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
    dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDiagnosticReportA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 ServiceRequest) What was requested
    ... category 0..* CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (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)

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base ServiceRequest) 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
    From the FHIR Standard
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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
    dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDiagnosticReportA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DiagnosticReport 0..* DiagnosticReport A diagnostic report in an Australian healthcare context
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... 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)
    ... 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)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
    From the FHIR Standard
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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
    dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDiagnosticReportA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Differential View

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 ServiceRequest) What was requested
    ... category 0..* CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (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)

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base ServiceRequest) 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
    From the FHIR Standard
    DiagnosticReport.categorypreferredDiagnosticServiceSectionCodes
    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
    dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDiagnosticReportA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

     

    Other representations of profile: CSV, Excel, Schematron