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 Pathology Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyreport Version: 4.2.2-ci-build
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBasePathologyReport

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

This profile defines a diagnostic report structure to represent a pathology report issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics.

This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.

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 pathology 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.
  • effective[x] is the earliest specimen collection date time.
  • The pathology laboratory is sent as a reference to an Organization in DiagnosticReport.performer.
  • Each pathologist is sent as a reference to a PractitionerRole resource in DiagnosticReport.performer.
  • When sending a discipline specific laboratory result, one of discipline specific value sets may be more suitable for use than the entire reporting value set bound in this profile to DiagnosticReport.code:

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 pathology 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) Pathology order
... category 1..* CodeableConcept Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... subject 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
... effective[x] 1..1 dateTime, Period Time of specimen collection
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result 0..* Reference(AU Base Diagnostic 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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* AUBaseDiagnosticReport A pathology 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 Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... code Σ 1..1 CodeableConcept Pathology test or test group
Binding: RCPA SPIA Pathology Reporting . (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 specimen collection
.... effectiveDateTime dateTime
.... effectivePeriod Period
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result 0..* Reference(AU Base Diagnostic 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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 pathology 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) Pathology order
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ 1..* CodeableConcept Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... code Σ 1..1 CodeableConcept Pathology test or test group
Binding: RCPA SPIA Pathology Reporting . (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 specimen collection
.... 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 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
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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 pathology 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) Pathology order
... category 1..* CodeableConcept Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... subject 1..1 Reference(Patient) The subject of the report - usually, but not always, the patient
... effective[x] 1..1 dateTime, Period Time of specimen collection
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result 0..* Reference(AU Base Diagnostic 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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCodepreferredClinicalFinding .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* AUBaseDiagnosticReport A pathology 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 Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... code Σ 1..1 CodeableConcept Pathology test or test group
Binding: RCPA SPIA Pathology Reporting . (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 specimen collection
.... effectiveDateTime dateTime
.... effectivePeriod Period
... specimen 0..* Reference(AU Base Specimen) Specimens this report is based on
... result 0..* Reference(AU Base Diagnostic 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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 pathology 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) Pathology order
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ 1..* CodeableConcept Service category
Binding: Pathology Diagnostic Service Category . (extensible)
... code Σ 1..1 CodeableConcept Pathology test or test group
Binding: RCPA SPIA Pathology Reporting . (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 specimen collection
.... 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 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
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.categoryextensiblePathologyDiagnosticServiceCategory .
https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredRCPASPIAPathologyReporting .
https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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