DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 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

4.22.7 Resource DiagnosticOrder - Detailed Descriptions

Detailed Descriptions for the elements in the DiagnosticOrder resource.

DiagnosticOrder
Definition

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

Control1..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).

Control1..1
TypeReference(Patient | Group | Location | Device)
Summarytrue
DiagnosticOrder.orderer
Definition

The practitioner that holds legal responsibility for ordering the investigation.

Control0..1
TypeReference(Practitioner)
Summarytrue
DiagnosticOrder.identifier
Definition

Identifiers assigned to this order by the order or by the receiver.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
DiagnosticOrder.encounter
Definition

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

Control0..1
TypeReference(Encounter)
Summarytrue
DiagnosticOrder.clinicalNotes
Definition

An explanation or justification for why this diagnostic investigation is being requested.

Control0..1
Typestring
Comments

This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all.

DiagnosticOrder.supportingInformation
Definition

Additional clinical information about the patient or specimen that may influence test interpretations.

Control0..*
TypeReference(Observation | Condition | DocumentReference)
Comments

This information includes diagnosis, clinical findings and other observations. Examples include reporting the amount of inspired carbon dioxide 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.

Control0..*
TypeReference(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.

Control0..1
BindingDiagnosticOrderStatus: Required: http://hl7.org/fhir/diagnostic-order-status (The status of a diagnostic order)
Typecode
Is Modifiertrue
Summarytrue
Comments

Typically the system placing the order sets the status to 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.

Control0..1
BindingDiagnosticOrderPriority: Required: http://hl7.org/fhir/diagnostic-order-priority (The clinical priority of a diagnostic order)
Typecode
Summarytrue
Comments

The Order resource also has a priority. Generally, these should be the same, but they can be different, for instance in the case where the clinician indicates that the order is urgent, but the subsequent workflow process overrule this 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. when the order was made, various processing steps (specimens received), when it was completed.

Control0..*
Comments

This is not the same as an audit 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.

Control1..1
BindingDiagnosticOrderStatus: Required: http://hl7.org/fhir/diagnostic-order-status (The status of a diagnostic order)
Typecode
Summarytrue
DiagnosticOrder.event.description
Definition

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

Control0..1
BindingDiagnosticOrderEventDescription: Example: 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)
TypeCodeableConcept
Summarytrue
DiagnosticOrder.event.dateTime
Definition

The date/time at which the event occurred.

Control1..1
TypedateTime
Summarytrue
DiagnosticOrder.event.actor
Definition

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

Control0..1
TypeReference(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.

Control0..*
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.

Control1..1
BindingDiagnosticRequests: Required: See http://hl7.org/fhir/vs/diagnostic-requests (Codes for tests/services that can be performed by diagnostic services)
TypeCodeableConcept
Summarytrue
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 specimen.

Control0..*
TypeReference(Specimen)
Comments

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

DiagnosticOrder.item.bodySite[x]
Definition

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

Control0..1
BindingBodySite: Example: See http://hl7.org/fhir/vs/body-site (Codes describing anatomical locations. May include laterality)
TypeCodeableConcept|Reference(BodySite)
Alternate Nameslocation
DiagnosticOrder.item.status
Definition

The status of this individual item within the order.

Control0..1
BindingDiagnosticOrderStatus: Required: http://hl7.org/fhir/diagnostic-order-status (The status of a diagnostic order)
Typecode
Summarytrue
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".

DiagnosticOrder.item.event
Definition

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

Control0..*
TypeSee DiagnosticOrder.event
Summarytrue