AU Base Implementation Guide
4.2.2-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 4.2.2-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: 4.2.2-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

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 Diagnostic Request | CarePlan) Diagnostic imaging order
... category 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
.... coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
... 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 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 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
Binding: DiagnosticServiceSectionCodes (preferred)
.... coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
... 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
... effective[x] Σ 1..1 Time of imaging examination
.... effectiveDateTime dateTime
.... effectivePeriod Period
... 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

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 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn 0..* Reference(ServiceRequest | AU Base Diagnostic 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)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
.... text Σ 0..1 string Plain text representation of the concept
... 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
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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()

This structure is derived from AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DiagnosticReport.category.coding

Maturity: 1

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 Diagnostic Request | CarePlan) Diagnostic imaging order
... category 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
.... coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
... 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 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 1..* CodeableConcept Relevant diagnostic imaging category: service, modality
Binding: DiagnosticServiceSectionCodes (preferred)
.... coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
... 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
... effective[x] Σ 1..1 Time of imaging examination
.... effectiveDateTime dateTime
.... effectivePeriod Period
... 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

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 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
... basedOn 0..* Reference(ServiceRequest | AU Base Diagnostic 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)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:system
.... text Σ 0..1 string Plain text representation of the concept
... 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
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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()

This structure is derived from AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DiagnosticReport.category.coding

Maturity: 1

 

Other representations of profile: CSV, Excel, Schematron