Path | Short | Definition | Comments |
---|---|---|---|
A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. | This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | |
identifier | Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). |
basedOn | What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. |
status | registered | partial | preliminary | final + | The status of the diagnostic report. | |
category | Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. |
code | Name/Code for this diagnostic report | A code or name that describes this diagnostic report. | |
subject | The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources. | |
encounter | Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). |
effective[x] | Clinically relevant time/time-period for report | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. |
issued | DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. |
performer | Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. |
resultsInterpreter | Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. |
specimen | Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. |
result | Observations | [Observations](observation.html) that are part of this diagnostic report. | Observations can contain observations. |
imagingStudy | Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. |
media | Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | |
media.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
media.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.comment | Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. |
media.link | Reference to the image source | Reference to the image source. | |
conclusion | Clinical conclusion (interpretation) of test results | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | |
conclusionCode | Codes for the clinical conclusion of test results | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | |
presentedForm | Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. |
This resource is an event resource from a FHIR workflow perspective - see Workflow. It is the intent of the Orders and Observation Workgroup to align this resource with the workflow pattern for event resources.
A diagnostic report is the set of information that is typically provided by a diagnostic service when investigations are complete. The information includes a mix of atomic results, text reports, images, and codes. The mix varies depending on the nature of the diagnostic procedure, and sometimes on the nature of the outcomes for a particular investigation. In FHIR, the report can be conveyed in a variety of ways including a Document, RESTful API, or Messaging framework. Included within each of these, would be the DiagnosticReport resource itself.
The DiagnosticReport resource has information about the diagnostic report itself, and about the subject and, in the case of laboratory tests, the specimen of the report. It can also refer to the request details and atomic observations details or image instances. Report conclusions can be expressed as a simple text blob, structured coded data or as an attached fully formatted report such as a PDF.
The DiagnosticReport resource is suitable for the following kinds of diagnostic reports:
The DiagnosticReport resource is not intended to support cumulative result presentation (tabular presentation of past and present results in the resource). The DiagnosticReport resource does not yet provide full support for detailed structured reports of sequencing; this is planned for a future release.
The words "tests", "results", "observations", "panels" and "batteries" are often used interchangeably when describing the various parts of a diagnostic report. This leads to much confusion. The naming confusion is worsened because of the wide variety of forms that the result of a diagnostic investigation can take, as described above. Languages other than English have their own variations on this theme.
This resource uses one particular set of terms. A practitioner "requests" a set of "tests". The diagnostic service returns a "report" which may contain a "narrative" - a written summary of the outcomes, and/or "results" - the individual pieces of atomic data which each are "observations". The results are assembled in "groups" which are nested structures of Observations (traditionally referred to as "panels" or " batteries" by laboratories) that can be used to represent relationships between the individual data items.
Note that many diagnostic processes are procedures that generate observations and diagnostic reports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the Procedure resource is used to describe the activity.
In contrast to the Observation resource, the DiagnosticReport resource typically includes additional clinical context and some mix of atomic results, images, imaging reports, textual and coded interpretation, and formatted representations. Laboratory reports, pathology reports, and imaging reports should be represented using the DiagnosticReport resource. The Observation resource is referenced by the DiagnosticReport to provide the atomic results for a particular investigation.
If you have a highly structured report, then use DiagnosticReport - it has data and workflow support. Details about the request for a diagnostic investigation are captured in the various "request" resources (e.g., the ServiceRequest) and allow the report to connect to clinical workflows. For more narrative driven reports with less work flow (histology/mortuary, etc.), the Composition resource would be more appropriate.
Image and media representations of the report and supporting images are referenced in the DiagnosticReport resource. The details and actual image instances can be referenced directly in Diagnostic report using the "imaging" element or by indirect reference through the ImagingStudy resources which represent the content produced in a DICOM imaging study or set of DICOM Instances for a patient.
type
element that may be used to distinguish the identifiers assigned by the requester and the performer of the request (known as the 'Placer' and 'Filler' in the HL7 Version 2 Messaging Standard). Use the identifier type code "PLAC" for the Placer Identifier and "FILL" for the Filler identifier as is shown in the example below:
<!-- Placer identifier--> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="PLAC"/> </coding> <text value="Placer"/> </type> <system value="urn:oid:1.3.4.5.6.7"/> <value value="2345234234234"/> </identifier> <!-- Filler identifier--> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="PLAC"/> </coding> <text value="Placer"/> </type> <system value=" http://terminology.hl7.org/CodeSystem/v2-0203"/> <value value="567890"/> </identifier>
If the diagnostic procedure was performed on the patient directly, the effective[x] element is a dateTime, the time it was performed. If specimens were taken, the clinically relevant time of the report can be derived from the specimen collection times, but since detailed specimen information is not always available, and nor is the clinically relevant time always exactly the specimen collection time (e.g. complex timed tests), the reports SHALL always include a effective[x] element. Note that HL7 v2 messages often carry a diagnostically relevant time without carrying any specimen information.
ImagingStudy and ImageObjectStudy and the media
element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Typically, a report is either: all data, no narrative (e.g. Core lab) or a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density), or all narrative (for example a typical imaging report, histopathology). This resource provides for these 3 different presentations:
Note that the conclusion and the coded diagnoses are part of the atomic data, and SHOULD be duplicated in the narrative and in the presented form if the latter is present. The narrative and the presented form serve the same function: a representation of the report for a human. The presented form is included since diagnostic service reports often contain presentation features that are not easy to reproduce in the HTML narrative. Whether or not the presented form is included, the narrative must be a clinically safe view of the diagnostic report; at a minimum, this could be fulfilled by a note indicating that the narrative is not proper representation of the report, and that the presented form must be used, or a generated view from the atomic data. However consumers of the report will best be served if the narrative contains clinically relevant data from the form. Commonly, the following patterns are used:
Note that the nature of reports from the various disciplines that provide diagnostic reports are changing quickly, as expert systems provide improved narrative reporting in high volume reports, structured reporting brings additional data to areas that have classically been narrative based, and the nature of the imaging and laboratory procedures are merging. As a consequence the patterns described above are only examples of how a diagnostic report can be used.
Genetic reporting makes heavy use of the DiagnosticReport and Observation resources. An implementation guide describing how to represent genetic results can be found here.
based-on | Reference to the service request. | DiagnosticReport.basedOn |
category | Which diagnostic discipline/department created the report | DiagnosticReport.category |
conclusion | A coded conclusion (interpretation/impression) on the report | DiagnosticReport.conclusionCode |
issued | When the report was issued | DiagnosticReport.issued |
media | A reference to the image source. | DiagnosticReport.media.link |
performer | Who is responsible for the report | DiagnosticReport.performer |
result | Link to an atomic result (observation resource) | DiagnosticReport.result |
results-interpreter | Who was the source of the report | DiagnosticReport.resultsInterpreter |
specimen | The specimen details | DiagnosticReport.specimen |
status | The status of the report | DiagnosticReport.status |
subject | The subject of the report | DiagnosticReport.subject |
Lipid Lab Report
Path | Short | Definition | Comments |
---|---|---|---|
Lipid Lab Report | The findings and interpretation of a general lipid lab profile. | In this profile, mustSupport means that authoring systems must include the ability to report these elements, and processing systems must cater for them by either displaying them to the user or considering them appropriately in decision support systems. | |
identifier | Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). |
basedOn | What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. |
status | registered | partial | preliminary | final + | The status of the diagnostic report. | |
category | Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. |
code | LOINC Code for Lipid Panel with LDL | LOINC Code for Lipid Panel with LDL. | LOINC code includes "direct" LDL - does this mean LDL derived by measuring VLDL by ultracentrifugation? This panel includes both measured and calculated LDL. |
subject | The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources. | |
encounter | Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). |
effective[x] | Clinically relevant time/time-period for report | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. |
issued | DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. |
performer | Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. |
resultsInterpreter | Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. |
specimen | Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. |
result | Observations | [Observations](observation.html) that are part of this diagnostic report. | Observations can contain observations. |
result | Cholesterol Result | Reference to Cholesterol Result. | Observations can contain observations. |
result | Triglyceride Result | Group of elements for Triglyceride result. | Observations can contain observations. |
result | HDL Cholesterol Result | Group of elements for HDL Cholesterol result. | Observations can contain observations. |
result | LDL Cholesterol result, if reported | LDL Cholesterol result, if reported. | Observations can contain observations. |
imagingStudy | Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. |
media | Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | |
media.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
media.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.comment | Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. |
media.link | Reference to the image source | Reference to the image source. | |
conclusion | Clinical Interpretation of Lipid Panel | May include diagnosis or suggestions for follow up testing. | It's not unusual for the lab to make some kind of interpretative comment on the set of results. |
conclusionCode | No codes for a lipid panel | No codes for a lipid panel. | Not used in this context. |
presentedForm | Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. |
Describes how the DiagnosticReport resource is used to report structured genetic test results
Path | Short | Definition | Comments |
---|---|---|---|
A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. | This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | |
identifier | Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). |
basedOn | What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. |
status | registered | partial | preliminary | final + | The status of the diagnostic report. | |
category | Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. |
code | Name/Code for this diagnostic report | A code or name that describes this diagnostic report. | |
subject | The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources. | |
encounter | Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). |
effective[x] | Clinically relevant time/time-period for report | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. |
issued | DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. |
performer | Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. |
resultsInterpreter | Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. |
specimen | Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. |
result | Observations | [Observations](observation.html) that are part of this diagnostic report. | Observations can contain observations. |
imagingStudy | Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. |
media | Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | |
media.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
media.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.comment | Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. |
media.link | Reference to the image source | Reference to the image source. | |
conclusion | Clinical conclusion (interpretation) of test results | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | |
conclusionCode | Codes for the clinical conclusion of test results | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | |
presentedForm | Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. |
Describes how the HLA genotyping results
Path | Short | Definition | Comments |
---|---|---|---|
A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. | This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | |
identifier | Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). |
basedOn | What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. |
status | registered | partial | preliminary | final + | The status of the diagnostic report. | |
category | Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. |
code | Name/Code for this diagnostic report | A code or name that describes this diagnostic report. | |
subject | The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources. | |
encounter | Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). |
effective[x] | Clinically relevant time/time-period for report | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. |
issued | DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. |
performer | Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. |
resultsInterpreter | Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. |
specimen | Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. |
result | Observations | [Observations](observation.html) that are part of this diagnostic report. | Observations can contain observations. |
imagingStudy | Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. |
media | Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | |
media.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
media.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
media.comment | Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. |
media.link | Reference to the image source | Reference to the image source. | |
conclusion | Clinical conclusion (interpretation) of test results | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | |
conclusionCode | Codes for the clinical conclusion of test results | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | |
presentedForm | Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. |