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4.16.7 Resource DiagnosticReport - Formal Definitions

Formal definitions for the elements in the DiagnosticReport resource.

DiagnosticReport
Definition 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 interpretation, and formatted representation of diagnostic reports.
Control 1..1
Requirements To support reporting for any diagnostic report into a clinical data repository.
Aliases Report; Test; Result; Results; Labs; Laboratory
Comments 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.
DiagnosticReport.name
Definition A code or name that describes this diagnostic report.
Control 1..1
Binding DiagnosticReportNames: LOINC Codes for Diagnostic Reports ( See http://hl7.org/fhir/vs/report-names )
Type CodeableConcept
DiagnosticReport.status
Definition The status of the diagnostic report as a whole.
Control 1..1
Binding DiagnosticReportStatus: The status of the diagnostic report as a whole (see http://hl7.org/fhir/diagnostic-report-status for values)
Type code
Is Modifier true
Requirements Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Summary true
Comments This is labeled as "Is Modifier" because applications need to take appropriate action if a report is withdrawn.
DiagnosticReport.issued
Definition The date and/or time that this version of the report was released from the source diagnostic service.
Control 1..1
Type dateTime
Requirements Clinicians need to be able to check the date that the report was released.
Aliases Date Created; Date published; Date Issued
Summary true
Comments 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.
DiagnosticReport.subject
Definition 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.
Control 1..1
Type Resource ( Patient | Group | Device | Location )
Requirements SHALL know the subject context.
Aliases Patient
Summary true
DiagnosticReport.performer
Definition The diagnostic service that is responsible for issuing the report.
Control 1..1
Type Resource ( Practitioner | Organization )
Requirements 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.
Aliases Laboratory; Service; Practitioner; Department; Company
Summary true
Comments This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.
DiagnosticReport.identifier
Definition The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider.
Control 0..1
Type Identifier
Requirements 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.
Aliases ReportID
Summary true
DiagnosticReport.requestDetail
Definition Details concerning a test requested.
Control 0..*
Type Resource ( DiagnosticOrder )
Requirements Need to be able to track completion of requests based on reports issued and also to report what diagnostic tests were requested (not always the same as what is delivered).
Comments 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.
DiagnosticReport.serviceCategory
Definition The section of the diagnostic service that performs the examination e.g. biochemistry, hematology, MRI.
Control 0..1
Binding DiagnosticServiceSection: HL7 v2 table 0074 ( See http://hl7.org/fhir/vs/diagnostic-service-sections )
Type CodeableConcept
Requirements Help clinicians filter/find the reports they are looking for.
Aliases Department; Sub-department; service; discipline
Summary true
DiagnosticReport.diagnostic[x]
Definition The time or time-period the observed values are related to. 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.
Control 1..1
Type dateTime | Period
Requirements Need to know where in the patient history to file/present this report.
Aliases Observation time; Effective Time
Summary true
Comments 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.
DiagnosticReport.specimen
Definition Details about the specimens on which this Disagnostic report is based.
Control 0..*
Type Resource ( Specimen )
Requirements Need to be able to report information about the collected specimens on which the report is based.
Comments 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.
DiagnosticReport.result
Definition 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").
Control 0..*
Type Resource ( Observation )
Requirements Need to be able to individual results, or report groups of results, where the result grouping is arbitrary, but meaningful. This structure is recursive - observations can contain observations.
Aliases Data; Atomic Value; Result; Atomic result; Data; Test; Analyte; Battery; Organiser
DiagnosticReport.imagingStudy
Definition 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.
Control 0..*
Type Resource ( ImagingStudy )
Comments ImagingStudy and image are somewhat overlapping - typically, an image in the image list will also be found in the imaging study resource. However the imaging study and image lists cater to different types of displays for different types of purposes. Neither, either, or both may be provided.
DiagnosticReport.image
Definition 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).
Control 0..*
Requirements Many diagnostic services include images in the report as part of their service.
Aliases DICOM; Slides; Scans
Summary true
DiagnosticReport.image.comment
Definition 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.
Control 0..1
Type string
Requirements The provider of the report should make a comment about each image included in the report.
Comments 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.
DiagnosticReport.image.link
Definition Reference to the image source.
Control 1..1
Type Resource ( Media )
Summary true
DiagnosticReport.conclusion
Definition Concise and clinically contextualized narrative interpretation of the diagnostic report.
Control 0..1
Type string
Requirements Need to be able to provide a conclusion that is not lost amongst the basic result data.
Aliases Report
Comments 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 (e.g. typical imaging report, histopathology)]. In all of these cases, the narrative goes in "text".
DiagnosticReport.codedDiagnosis
Definition Codes for the conclusion.
Control 0..*
Binding AdjunctDiagnosis: SNOMED CT Clinical Findings ( See http://hl7.org/fhir/vs/clinical-findings )
Type CodeableConcept
DiagnosticReport.presentedForm
Definition Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Control 0..*
Type Attachment
Requirements Gives Laboratory the ability to provide its own fully formatted report for clinical fidelity.
Comments Application/pdf is recommended as the most reliable and interoperable in this context.
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