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
Formal
definitions
Detailed
Descriptions
for
the
elements
in
the
DiagnosticOrder
resource.
| 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 |
|
| Summary | true |
| DiagnosticOrder.orderer | |
| Definition |
The practitioner that holds legal responsibility for ordering the investigation. |
| Control | 0..1 |
| Type |
|
| Summary | true |
| DiagnosticOrder.identifier | |
| Definition |
Identifiers
assigned
to
this
order
instance
by
the
|
| 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
|
| Control | 0..1 |
| Type |
|
| Summary | true |
|
|
|
| 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 |
|
| Binding | Condition/Problem/Diagnosis Codes: Diagnosis or problem codes justifying the reason for requesting the diagnostic investigation. ( Example ) |
| Type |
|
| 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 . |
|
|
|
| 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 |
|
| 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
|
| Type | code |
| Is Modifier | true |
| Summary | true |
| Comments |
Typically
the
system
placing
the
order
sets
the
status
to
|
| DiagnosticOrder.priority | |
| Definition |
The clinical priority associated with this order. |
| Control | 0..1 |
| Binding |
DiagnosticOrderPriority:
The
clinical
priority
of
a
diagnostic
|
| Type | code |
| Summary | true |
| Comments |
The
Order
resource
also
has
a
priority.
Generally,
these
should
be
the
same,
but
they
can
be
|
| DiagnosticOrder.event | |
| Definition |
A
summary
of
the
events
of
interest
that
have
occurred
as
the
request
is
|
| Control | 0..* |
| Comments |
This
is
not
the
same
as
an
audit
|
| DiagnosticOrder.event.status | |
| Definition |
The status for the event. |
| Control | 1..1 |
| Binding |
DiagnosticOrderStatus:
The
status
of
a
diagnostic
|
| 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 |
|
| 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
|
| Control | 0..1 |
| Type |
|
| 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 |
|
| 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
|
| Control | 0..* |
| Type |
|
| Comments |
A
single
specimen
should
not
appear
in
both
|
| DiagnosticOrder.item.bodySite | |
| Definition |
Anatomical location where the request test should be performed. This is the target site. |
| Control | 0..1 |
| Binding |
|
| Type | CodeableConcept |
| Alternate Names | location |
|
|
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
|
| 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)
|
| 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 |