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/mjosborne1/mjo-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.

Usages:

  • This 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 & 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)

    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 & 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
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
    ... category Σ 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

    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 & 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
    ... 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 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

    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 & 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)

    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 & 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
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber Business identifier for report
    ... status ?!Σ 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
    ... category Σ 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

    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 & 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
    ... 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 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

    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