AU Base Implementation Guide
5.0.1-ci-build - CI Build Australia flag

AU Base Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 5.0.1-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

Resource Profile: AU Base Diagnostic Imaging Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-imagingreport Version: 5.0.1-ci-build
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBaseDiagnosticImagingReport

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

This profile defines a diagnostic report structure to represent a diagnostic imaging report issued by a diagnostic service provider in an Australian context.

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 imaging examination and result value or component result values, or a nested grouping of Observations such as a multi-modality procedure which references other Observations in Observation.hasMember.
  • When constructing a report for a nested grouping of Observations:
    • the individual imaging examinations are referenced by that grouping Observation in Observation.hasMember and not directly referenced in DiagnosticReport.result
    • DiagnosticReport.code and the grouping Observation Observation.code should be the same concept if the report contains only the results of that group.
  • See each Identifier profile page for guidance related to that identifier type.
  • The radiology laboratory is sent as a reference to an Organization in DiagnosticReport.performer.
  • Each radiologist is sent as a references to a PractitionerRole resource in DiagnosticReport.performer.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Changes since version 5.0.0:

  • No changes
  • 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 0..* AUBaseDiagnosticReport A diagnostic imaging report in an Australian healthcare context
    ... identifier 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... basedOn 0..* Reference(ServiceRequest | AU Base Service Request | CarePlan) Diagnostic imaging order
    ... category 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    ... subject 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
    ... effective[x] 1..1 dateTime, Period Time of imaging examination
    ... result 0..* Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
    DiagnosticReport.conclusionCodepreferredClinicalFinding .
    https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport 0..* AUBaseDiagnosticReport A diagnostic imaging report in an Australian healthcare context
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: 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
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ele-1: All FHIR elements must have a @value or children
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


    ele-1: All FHIR elements must have a @value or children
    ... category Σ 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    Binding: DiagnosticServiceSectionCodes (preferred)
    ele-1: All FHIR elements must have a @value or children
    ... code Σ 1..1 CodeableConcept Diagnostic imaging examination or study
    Binding: Imaging Procedure . (preferred)
    ele-1: All FHIR elements must have a @value or children
    ... subject Σ 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
    ele-1: All FHIR elements must have a @value or children
    ... effective[x] Σ 1..1 Time of imaging examination
    ele-1: All FHIR elements must have a @value or children
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    ... result 0..* Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) Observations
    ele-1: All FHIR elements must have a @value or children
    ... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
    Binding: Clinical Finding . (preferred)
    ele-1: All FHIR elements must have a @value or children

    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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-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()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport 0..* AUBaseDiagnosticReport A diagnostic imaging 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
    ... 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(ServiceRequest | AU Base Service Request | CarePlan) Diagnostic imaging order
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

    ... category Σ 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    Binding: DiagnosticServiceSectionCodes (preferred)
    ... code Σ 1..1 CodeableConcept Diagnostic imaging examination or study
    Binding: Imaging Procedure . (preferred)
    ... subject Σ 1..1 Reference(Patient) 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 1..1 Time of imaging examination
    .... 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(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-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 AUBaseDiagnosticReport

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport 0..* AUBaseDiagnosticReport A diagnostic imaging report in an Australian healthcare context
    ... identifier 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... basedOn 0..* Reference(ServiceRequest | AU Base Service Request | CarePlan) Diagnostic imaging order
    ... category 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    ... subject 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
    ... effective[x] 1..1 dateTime, Period Time of imaging examination
    ... result 0..* Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
    DiagnosticReport.conclusionCodepreferredClinicalFinding .
    https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport 0..* AUBaseDiagnosticReport A diagnostic imaging report in an Australian healthcare context
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: 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
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ele-1: All FHIR elements must have a @value or children
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


    ele-1: All FHIR elements must have a @value or children
    ... category Σ 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    Binding: DiagnosticServiceSectionCodes (preferred)
    ele-1: All FHIR elements must have a @value or children
    ... code Σ 1..1 CodeableConcept Diagnostic imaging examination or study
    Binding: Imaging Procedure . (preferred)
    ele-1: All FHIR elements must have a @value or children
    ... subject Σ 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
    ele-1: All FHIR elements must have a @value or children
    ... effective[x] Σ 1..1 Time of imaging examination
    ele-1: All FHIR elements must have a @value or children
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    ... result 0..* Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) Observations
    ele-1: All FHIR elements must have a @value or children
    ... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
    Binding: Clinical Finding . (preferred)
    ele-1: All FHIR elements must have a @value or children

    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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-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()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport 0..* AUBaseDiagnosticReport A diagnostic imaging 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
    ... 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(ServiceRequest | AU Base Service Request | CarePlan) Diagnostic imaging order
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

    ... category Σ 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
    Binding: DiagnosticServiceSectionCodes (preferred)
    ... code Σ 1..1 CodeableConcept Diagnostic imaging examination or study
    Binding: Imaging Procedure . (preferred)
    ... subject Σ 1..1 Reference(Patient) 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 1..1 Time of imaging examination
    .... 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(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.codepreferredImagingProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/imaging-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