DSTU2

This page is part of the FHIR Specification (v0.0.82: (v1.0.2: DSTU 1). 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions

4.17.7 4.22.7 Resource DiagnosticOrder - Formal Definitions Detailed Descriptions

Formal definitions Detailed Descriptions for the elements in the DiagnosticOrder resource.

Aliases Report; Test; Result; Results; Labs; Laboratory Aliases
DiagnosticOrder
Definition

A record of a request for a diagnostic investigation service to be performed.

Control 1..1
DiagnosticOrder.subject
Definition

Who or what the investigation is to be performed on. This is usually a human patient, but diagnostic tests can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans).

Control 1..1
Type Resource Reference ( Patient | Group | Location | Device )
Summary true
DiagnosticOrder.orderer
Definition

The practitioner that holds legal responsibility for ordering the investigation.

Control 0..1
Type Resource Reference ( Practitioner )
Summary true
DiagnosticOrder.identifier
Definition

Identifiers assigned to this order instance by the order or by orderer and/or the receiver. receiver and/or order fulfiller.

Note This is a business identifer, not a resource identifier (see discussion )
Control 0..*
Type Identifier
Summary true
Comments

The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the notes section below.

DiagnosticOrder.encounter
Definition

An encounter that provides additional informaton information about the healthcare context in which this request is made.

Control 0..1
Type Resource Reference ( Encounter )
Summary true
DiagnosticOrder.clinicalNotes DiagnosticOrder.reason
Definition

An explanation or justification for why this diagnostic investigation is being requested. This is often for billing purposes. May relate to the resources referred to in supportingInformation.

Control 0..1 0..*
Binding Condition/Problem/Diagnosis Codes: Diagnosis or problem codes justifying the reason for requesting the diagnostic investigation. ( Example )
Type string CodeableConcept
Comments

This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the CT Scan example .

DiagnosticOrder.specimen DiagnosticOrder.supportingInformation
Definition

Additional clinical information about the patient or specimen that may influence test interpretations. This includes observations explicitly requested by the producer(filler) to provide context or supporting information needed to complete the order.

Control 0..*
Type Reference ( Observation | Condition | DocumentReference )
Alternate Names Ask at order entry question; AOE
Comments

This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". Examples include reporting the amount of inspired oxygen for blood gasses, the point in the menstrual cycle for cervical pap tests, and other conditions that influence test interpretations.

DiagnosticOrder.specimen
Definition

One or more specimens that the diagnostic investigation is about.

Control 0..*
Type Resource Reference ( Specimen )
Comments

Many investigation requests will create a need for specimens, but the request itself is not actually about the specimens. This is provided for when the diagnostic investigation is requested on already existing specimens.

DiagnosticOrder.status
Definition

The status of the order.

Control 0..1
Binding DiagnosticOrderStatus: The status of a diagnostic order (see http://hl7.org/fhir/diagnostic-order-status order. for values) ( Required )
Type code
Is Modifier true
Summary true
Comments

Typically the system placing the order sets the status to requested. There after, "requested". Thereafter, the order is maintained by the receiver that updates the status as the request is handled.

DiagnosticOrder.priority
Definition

The clinical priority associated with this order.

Control 0..1
Binding DiagnosticOrderPriority: The clinical priority of a diagnostic order (see http://hl7.org/fhir/diagnostic-order-priority order. for values) ( Required )
Type code
Summary true
Comments

The Order resource also has a priority. Generally, these should be the same, but they can be different, for instance in the case different. For instance, where the clinician indicates that the order is urgent, but the subsequent workflow process overrule this overrules the priority for some reason. The effective default value is "normal".

DiagnosticOrder.event
Definition

A summary of the events of interest that have occurred as the request is processed. E.g. processed; e.g. when the order was made, various processing steps (specimens received), when it was completed.

Control 0..*
Comments

This is not the same as an audit trail - it trail. It is a view of the important things that happened in the past. Typically, there would only be one entry for any given status, and systems may not record all the status events.

DiagnosticOrder.event.status
Definition

The status for the event.

Control 1..1
Binding DiagnosticOrderStatus: The status of a diagnostic order (see http://hl7.org/fhir/diagnostic-order-status order. for values) ( Required )
Type code
Summary true
DiagnosticOrder.event.description
Definition

Additional information about the event that occurred - e.g. if the status remained unchanged.

Control 0..1
Binding DIagnosticOrderEventDescription: ( Diagnostic Order Event Codes: See http://hl7.org/fhir/vs/diagnostic-order-event Additional information about an event that occurred to a diagnostic order - e.g. if the status remained unchanged. ( Example )
Type CodeableConcept
Summary true
DiagnosticOrder.event.dateTime
Definition

The date/time at which the event occurred.

Control 1..1
Type dateTime
Summary true
DiagnosticOrder.event.actor
Definition

The person who was responsible for performing or recording the action.

Control 0..1
Type Resource Reference ( Practitioner | Device )
DiagnosticOrder.item
Definition

The specific diagnostic investigations that are requested as part of this request. Sometimes, there can only be one item per request, but in most contexts, more than one investigation can be requested.

Control 0..*
Comments

There would always be at least one item in normal usage, but this is optional so that a workflow can quote order details without having to list the items.

DiagnosticOrder.item.code
Definition

A code that identifies a particular diagnostic investigation, or panel of investigations, that have been requested.

Control 1..1
Binding DiagnosticRequests: LOINC Diagnostic Order Codes: Codes for tests/services that can be performed by diagnostic services. ( See http://hl7.org/fhir/vs/diagnostic-requests Preferred )
Type CodeableConcept
Summary true
Comments

Many laboratory tests and radiology tests embed the specimen/organ system in the test name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code.

DiagnosticOrder.item.specimen
Definition

If the item is related to a specific speciment. specimen.

Control 0..*
Type Resource Reference ( Specimen )
Comments

A single specimen should not appear in both DIagnosticOrder.specimen DiagnosticOrder.specimen and DiagnosticOrder.item.specimen.

DiagnosticOrder.item.bodySite
Definition

Anatomical location where the request test should be performed. This is the target site.

Control 0..1
Binding BodySite: SNOMED CT Body site concepts ( Structures: See http://hl7.org/fhir/vs/body-site Codes describing anatomical locations. May include laterality. ( Example )
Type CodeableConcept
Alternate Names location
To Do Comments Is this approach or target site?.

If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension body-site-instance .

DiagnosticOrder.item.status
Definition

The status of this individual item within the order.

Control 0..1
Binding DiagnosticOrderStatus: The status of a diagnostic order (see http://hl7.org/fhir/diagnostic-order-status order. for values) ( Required )
Type code
Summary true
Comments

If the request has multiple items that have their own life cycles, then the items will have their own status while the overall diagnostic order is (usually) "in progress". "in-progress".

DiagnosticOrder.item.event
Definition

A summary of the events of interest that have occurred as this item of the request is processed.

Control 0..*
Type See DiagnosticOrder.event
Summary true
DiagnosticOrder.note
Definition

Any other notes associated with this patient, specimen or order (e.g. "patient hates needles").

Control 0..*
Type Annotation
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