Diagnostics
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| Orders and Observations Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
HLAResult
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.
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or
a meta.lastUpdated
If the resource is contained in another resource, it SHALL be referred to from elsewhere
in the resource
not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f
:reference/@value=concat('#', $id))]))
The logical id of the resource, as used in the URL for the resource. Once assigned, this
value never changes.
The only time that a resource does not have an id is when it is being submitted to the
server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure.
Changes to the content may not always be associated with version changes to the resource.
A reference to a set of rules that were followed when the resource was constructed, and
which must be understood when processing the content.
Asserting this rule set restricts the content to be only understood by a limited set of
trading partners. This inherently limits the usefulness of the data in the long term.
However, the existing health eco-system is highly fractured, and not yet ready to define,
collect, and exchange data in a generally computable sense. Wherever possible, implementers
and/or specification writers should avoid using this element.
This element is labelled as a modifier because the implicit rules may provide additional
knowledge about the resource that modifies it's meaning or interpretation.
Language is provided to support indexing and accessibility (typically, services such as
text to speech use the language tag). The html language tag in the narrative applies
to the narrative. The language tag on the resource may be used to specify the language
of other presentations generated from the data in the resource Not all the content has
to be in the base language. The Resource.language should not be assumed to apply to the
narrative automatically. If a language is specified, it should it also be specified on
the div element in the html (see rules in HTML5 for information about the relationship
between xml:lang and the html lang attribute).
A human-readable narrative that contains a summary of the resource, and may be used to
represent the content of the resource to a human. The narrative need not encode all the
structured data, but is required to contain sufficient detail to make it "clinically
safe" for a human to just read the narrative. Resource definitions may define what
content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have
a narrative. In some cases, a resource may only have text with little or no additional
discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary
for data from legacy systems where information is captured as a "text blob"
or where text is additionally entered raw or narrated and encoded in formation is added
later.
These resources do not have an independent existence apart from the resource that contains
them - they cannot be identified independently, and nor can they have their own independent
transaction scope.
This should never be done when the content can be identified properly, as once identification
is lost, it is extremely difficult (and context dependent) to restore it again.
May be used to represent additional information that is not part of the basic definition
of the resource, and that modifies the understanding of the element that contains it.
Usually modifier elements provide negation or qualification. In order 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 is allowed to 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.
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.
Usually assigned by the Information System of the diagnostic service provider (filler
id).
Need to know what identifier to use when making queries about this report from the source
laboratory, and for linking to the report outside FHIR context.
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.
This allows tracing of authorization for the report and tracking whether proposals/recommendations
were acted upon.
This is labeled as "Is Modifier" because applications need to take appropriate
action if a report is withdrawn.
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw
previously released reports.
statusCode Note: final and amended are distinguished by whether observation is the subject
of a ControlAct event of type "revise"
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.
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.
OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed
panel)
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.
The healthcare event (e.g. a patient and healthcare provider interaction) which this
DiagnosticReport per 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 or episode but still
be tied to the context of the encounter or episode (e.g. pre-admission lab tests).
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.
The date and time that this version of the report was released from the source diagnostic
service.
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.
unique id for the element within a resource (for internal references). This may be any
string value that does not contain spaces.
May be used to represent additional information that is not part of the basic definition
of the element. In order 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 is allowed to 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.
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 that contains it. Usually
modifier elements provide negation or qualification. In order 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 is allowed to 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.
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.
The reference to the practitioner or organization involved in producing the report. For
example, the diagnostic service that is responsible for issuing the report.
This is not necessarily the source of the atomic data items. It is the entity that takes
responsibility for the clinical report.
Need to know whom to contact if there are queries about the results. Also may need to
track the source of reports for secondary data analysis.
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.
Need to be able to report information about the collected specimens on which the report
is based.
Observations that are part of this diagnostic report. Observations can be simple name/value
pairs (e.g. "atomic" results), or they can be grouping observations that include
references to other members of the group (e.g. "panels").
Need to support individual results, or report groups of results, where the result grouping
is arbitrary, but meaningful. This structure is recursive - observations can contain observations.
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 ImageManifest 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.
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).
unique id for the element within a resource (for internal references). This may be any
string value that does not contain spaces.
May be used to represent additional information that is not part of the basic definition
of the element. In order 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 is allowed to 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.
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 that contains it. Usually
modifier elements provide negation or qualification. In order 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 is allowed to 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.
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.
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.
.inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"]
.value
inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-
8].value (type=ST)
inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value
(type=CD)
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.
</
StructureDefinition
Raw
JSON
>
(
canonical
form
+
also
see
JSON
Format
Specification
)
Example of an Observations made about a location - an oyster farm
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR
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FHIR
Release
3
(STU;
v3.0.2-11200)
R5
Ballot
hl7.fhir.core#5.0.0-snapshot3
generated
on
Thurs,
Oct
24,
2019
11:53+1100.
QA
Page
Wed,
Dec
14,
2022
07:17+1100.
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