AU Base Implementation Guide
6.0.0-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 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 Diagnostic Imaging Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-imagingreport Version: 6.0.0-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.
  • This profile supports the sex, gender, and related concepts of: Sex Parameter for Clinical Use:

Usages:

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

You can also check for usages in the FHIR IG Statistics

Changes since version 5.0.0:

  • No changes

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... Slices for extension Content/Rules for all slices
    .... extension:sexParameterForClinicalUse 0..* (Complex) A context-specific sex parameter for clinical use
    URL: http://hl7.org/fhir/StructureDefinition/patient-sexParameterForClinicalUse
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... basedOn 0..* Reference(ServiceRequest | AU Base ServiceRequest | 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
    ... 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

    Path Status Usage ValueSet Version Source
    DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
    DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error DiagnosticReport 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 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

    This structure is derived from AUBaseDiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 ServiceRequest | 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)

    Path Status Usage ValueSet Version Source
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:sexParameterForClinicalUse 0..* (Complex) A context-specific sex parameter for clinical use
    URL: http://hl7.org/fhir/StructureDefinition/patient-sexParameterForClinicalUse
    ... 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 ServiceRequest | 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

    Path Status Usage ValueSet Version Source
    DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
    DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error DiagnosticReport 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 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... Slices for extension Content/Rules for all slices
    .... extension:sexParameterForClinicalUse 0..* (Complex) A context-specific sex parameter for clinical use
    URL: http://hl7.org/fhir/StructureDefinition/patient-sexParameterForClinicalUse
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... basedOn 0..* Reference(ServiceRequest | AU Base ServiceRequest | 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
    ... 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

    Path Status Usage ValueSet Version Source
    DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
    DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error DiagnosticReport 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 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

    Differential View

    This structure is derived from AUBaseDiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 ServiceRequest | 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)

    Path Status Usage ValueSet Version Source
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:sexParameterForClinicalUse 0..* (Complex) A context-specific sex parameter for clinical use
    URL: http://hl7.org/fhir/StructureDefinition/patient-sexParameterForClinicalUse
    ... 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 ServiceRequest | 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

    Path Status Usage ValueSet Version Source
    DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
    DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
    DiagnosticReport.code Base preferred Imaging Procedure . ⏿1.0.2 tx.ontoserver.csiro.au
    DiagnosticReport.conclusionCode Base preferred Clinical Finding . ⏿1.0.2 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error DiagnosticReport 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 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-4 error DiagnosticReport If 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

     

    Other representations of profile: CSV, Excel, Schematron