STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

??.?? Logical Model nehta-specialist-letter - Content

Document containing information about a specialist consultation.

??.??.1 Scope and Usage

TO DO

??.??.2 Boundaries and Relationships

TO DO

??.??.3 Background and Context

TO DO

??.??.4 Logical Model Content

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. SpecialistLetter LogicalSpecialist Letter
... subjectofCare 1..1Reference(Patient)Subject of Care
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document Author
... encounter 1..1ElementEncounter
.... dateTimeHealthEventStarted 1..1dateTimeDateTime Health Event Started
... documentType 1..1IdentifierDocument Type
... usualGP 0..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Usual GP
... referrer 1..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Referrer
... dateTimeAttested 1..1dateTimeDateTime Attested
... responseDetails 1..1ElementResponse Details
.... problemDiagnosis 0..*ElementProblem/Diagnosis
..... identification 1..1CodeableConceptProblem/Diagnosis Identification
.... procedure 0..*ElementProcedure
..... name 1..1CodeableConceptProcedure Name
..... dateTime 1..1PeriodProcedure DateTime
.... clinicalSynopsis 0..*ElementClinical Synopsis
..... description 1..1stringClinical Synopsis Description
.... clinicalSynopsis2 1..1ElementClinical Synopsis
..... description 1..1stringClinical Synopsis Description
... recommendations 1..1ElementRecommendations
.... recommendation 0..*ElementRecommendation
..... addressee 1..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Addressee
..... timeFrame 1..1dateTimeRecommendation Time Frame
..... narrative 1..1stringRecommendation Narrative
.... exclusionStatement 0..1ElementExclusion Statement
..... generalStatement 1..1stringGeneral Statement
... medicationOrders 1..1ElementMedication Orders
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medications
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)
.... medicationInstruction 0..*ElementMedication Instruction
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)
..... directions 0..1stringDirections
..... clinicalIndication 0..1stringClinical Indication
..... comment 0..1stringMedication Instruction Comment
..... changeType 1..1CodeableConceptChange Type
..... changeStatus 1..1CodeableConceptChange Status
..... changeDescription 0..1stringChange Description
..... changeorRecommendationReason 0..1stringChange or Recommendation Reason
..... narrative 1..1stringMedication Instruction Narrative
..... dateTimeMedicationInstructionExpires 1..1dateTimeDateTime Medication Instruction Expires
... adverseReactions 0..1ElementAdverse Reactions
.... adverseReaction 1..*ElementAdverse Reaction
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)
..... event 0..1ElementReaction Event
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)
... diagnosticInvestigations 0..1ElementDiagnostic Investigations
.... pathologyTestResult 0..*ElementPathology Test Result
..... name 1..1CodeableConceptPathology Test Result Name
..... diagnosticService 0..1CodeableConceptDiagnostic Service
..... specimen 1..*ElementSpecimen
...... tissueType 0..1CodeableConceptSpecimen Tissue Type
...... collectionProcedure 0..1CodeableConceptCollection Procedure
...... anatomicalLocation 0..*ElementAnatomical Location
....... specificLocation 0..1ElementSpecific Location
........ anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
........ side 0..1CodeableConceptSide
....... description 0..1stringAnatomical Location Description
....... image 0..*base64BinaryAnatomical Location Image
...... physicalPropertiesofanObject 0..*ElementPhysical Properties of an Object
....... weight 0..1QuantityWeight
....... dimensions 0..1ElementDimensions
........ volume 0..1QuantityVolume
....... objectDescription 0..1stringObject Description
....... image 0..1base64BinaryImage
...... collectionandHandling 0..1ElementCollection and Handling
....... samplingPreconditions 0..1CodeableConceptSampling Preconditions
...... handlingandProcessing 1..1ElementHandling and Processing
....... collectionDateTime 1..1dateTimeCollection DateTime
....... collectionSetting 0..1stringCollection Setting
....... dateTimeReceived 0..1dateTimeDateTime Received
...... identifiers 0..1ElementIdentifiers
....... specimenIdentifier 0..1IdentifierSpecimen Identifier
....... parentSpecimenIdentifier 0..1IdentifierParent Specimen Identifier
....... containerIdentifier 0..1IdentifierContainer Identifier
..... overallPathologyTestResultStatus 1..1CodeableConceptOverall Pathology Test Result Status
PathologyTestResultStatusValues (Required)
..... clinicalInformationProvided 0..1stringClinical Information Provided
..... group 0..*ElementPathology Test Result Group
...... name 1..1CodeableConceptPathology Test Result Group Name
...... individualPathologyTestResult 1..*ElementIndividual Pathology Test Result
....... name 1..1CodeableConceptIndividual Pathology Test Result Name
....... value 0..1ElementIndividual Pathology Test Result Value
........ value 1..1CodeableConceptIndividual Pathology Test Result Value
........ referenceRangeDetails 0..1ElementReference Range Details
......... normalStatus 0..1CodeableConceptNormal Status
......... referenceRange 0..*ElementReference Range
.......... meaning 1..1CodeableConceptReference Range Meaning
.......... referenceRange 0..1RangeReference Range
....... comment 0..*stringIndividual Pathology Test Result Comment
....... referenceRangeGuidance 0..1stringIndividual Pathology Test Result Reference Range Guidance
....... status 1..1CodeableConceptIndividual Pathology Test Result Status
PathologyTestResultStatusValues (Required)
...... specimen 0..1ElementSpecimen
....... tissueType 0..1CodeableConceptSpecimen Tissue Type
....... collectionProcedure 0..1CodeableConceptCollection Procedure
....... anatomicalLocation 0..*ElementAnatomical Location
........ specificLocation 0..1ElementSpecific Location
......... anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
......... side 0..1CodeableConceptSide
........ description 0..1stringAnatomical Location Description
........ image 0..*base64BinaryAnatomical Location Image
....... physicalPropertiesofanObject 0..*ElementPhysical Properties of an Object
........ weight 0..1QuantityWeight
........ dimensions 0..1ElementDimensions
......... volume 0..1QuantityVolume
........ objectDescription 0..1stringObject Description
........ image 0..1base64BinaryImage
....... collectionandHandling 0..1ElementCollection and Handling
........ samplingPreconditions 0..1CodeableConceptSampling Preconditions
....... handlingandProcessing 1..1ElementHandling and Processing
........ collectionDateTime 1..1dateTimeCollection DateTime
........ collectionSetting 0..1stringCollection Setting
........ dateTimeReceived 0..1dateTimeDateTime Received
....... identifiers 0..1ElementIdentifiers
........ specimenIdentifier 0..1IdentifierSpecimen Identifier
........ parentSpecimenIdentifier 0..1IdentifierParent Specimen Identifier
........ containerIdentifier 0..1IdentifierContainer Identifier
..... pathologicalDiagnosis 0..*CodeableConceptPathological Diagnosis
..... pathologyTestConclusion 0..1stringPathology Test Conclusion
..... representation 0..1base64BinaryTest Result Representation
..... testComment 0..1stringTest Comment
..... testRequestDetails 0..*ElementTest Request Details
...... testRequestedName 0..*CodeableConceptTest Requested Name
...... laboratoryTestResultIdentifier 0..1IdentifierLaboratory Test Result Identifier
..... observationDateTime 1..1PeriodObservation DateTime
.... imagingExaminationResult 0..*ElementImaging Examination Result
..... name 1..1CodeableConceptImaging Examination Result Name
..... imagingModality 0..1CodeableConceptImaging Modality
..... anatomicalLocation 0..*ElementAnatomical Location
...... specificLocation 0..1ElementSpecific Location
....... anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
....... side 0..1CodeableConceptSide
...... description 0..1stringAnatomical Location Description
...... image 0..*base64BinaryAnatomical Location Image
..... status 1..1CodeableConceptImaging Examination Result Status
ImagingExaminationResultStatusValues (Required)
..... clinicalInformationProvided 0..1stringClinical Information Provided
..... findings 0..1stringFindings
..... group 0..*ElementImaging Examination Result Group
...... name 1..1CodeableConceptImaging Examination Result Group Name
...... individualImagingExaminationResult 1..*ElementIndividual Imaging Examination Result
....... name 1..1CodeableConceptIndividual Imaging Examination Result Name
....... value 0..1ElementImaging Examination Result Value
........ value 1..1CodeableConceptImaging Examination Result Value
........ referenceRangeDetails 0..1ElementReference Range Details
......... normalStatus 0..1CodeableConceptNormal Status
......... referenceRange 0..*ElementReference Range
.......... meaning 1..1CodeableConceptReference Range Meaning
.......... referenceRange 0..1RangeReference Range
....... resultComment 0..*stringResult Comment
...... anatomicalLocation 0..1ElementAnatomical Location
....... specificLocation 0..1ElementSpecific Location
........ anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
........ side 0..1CodeableConceptSide
....... description 0..1stringAnatomical Location Description
....... image 0..*base64BinaryAnatomical Location Image
..... representation 0..1base64BinaryExamination Result Representation
..... examinationRequestDetails 0..*ElementExamination Request Details
...... examinationRequestedName 0..*CodeableConceptExamination Requested Name
...... dICOMStudyIdentifier 0..1IdentifierDICOM Study Identifier
...... reportIdentifier 0..1IdentifierReport Identifier
...... imageDetails 0..*ElementImage Details
....... imageIdentifier 0..1IdentifierImage Identifier
....... dICOMSeriesIdentifier 0..1IdentifierDICOM Series Identifier
....... imageViewName 0..1CodeableConceptImage View Name
....... subjectPosition 0..1CodeableConceptSubject Position
....... imageDateTime 0..1dateTimeImage DateTime
....... image 0..1base64BinaryImage
..... observationDateTime 1..1PeriodObservation DateTime
.... requestedService 0..*ElementRequested Service
..... description 1..1CodeableConceptRequested Service Description
..... dateTimeServiceScheduled 0..1dateTimeDateTime Service Scheduled
..... commencementWindow 0..1PeriodService Commencement Window
..... bookingStatus 1..1CodeableConceptService Booking Status
ServiceBookingStatusValues (Required)
..... subjectofCareInstructionDescription 0..1stringSubject of Care Instruction Description
..... provider 0..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Service Provider
..... dateTime 1..1dateTimeRequested Service DateTime

doco Documentation for this format

UML Diagram

SpecialistLetter (Logical)Identification information about the patient that has been referred and is the subject of this specialist lettersubjectofCare : Reference [1..1] « Patient »The healthcare provider who is the source of this specialist letterdocumentAuthor : Reference [1..1] « Patient|Practitioner| RelatedPerson|Device »The NEHTA OID for the document exchange scenario(s) - i.e. the type of document - represented by this Structured Document. This is a fixed value (1.2.36.1.2001.1001.101.100.16615) for all instances of a Specialist Letter composition. Type of documentdocumentType : Identifier [1..1]A healthcare provider (person or organisation) nominated by the subject of care as being primarily responsible for their ongoing healthcareusualGP : Reference [0..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The healthcare provider from whom the subject of care was referred to this specialistreferrer : Reference [1..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The date (and time if known) that the document author or document authoriser/approver confirms (usually by signature) that a document is complete and genuinedateTimeAttested : dateTime [1..1]EncounterThe date and time when the specialist consultation took placedateTimeHealthEventStarted : dateTime [1..1]ResponseDetailsProblemDiagnosisIdentification of the problem or diagnosisidentification : CodeableConcept [1..1]ProcedureThe name of the procedure (to be) performedname : CodeableConcept [1..1]Date, and optionally time, of the Procedure actiondateTime : Period [1..1]ClinicalSynopsisShort description, overview or summary of a clinical event and its reasonsdescription : string [1..1]ClinicalSynopsis2Short description, overview or summary of a clinical event and its reasonsdescription : string [1..1]RecommendationsRecommendationThe intended recipient of the recommendationaddressee : Reference [1..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The time or time period for which the recommendation appliestimeFrame : dateTime [1..1]A textual narrative describing what the recommendation instruction is aboutnarrative : string [1..1]ExclusionStatementA general statement about the absence or exclusion of data valuesgeneralStatement : string [1..1]MedicationOrdersExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the statement about the absence or exclusion. (Strength=Required)GlobalStatementValues! »MedicationInstructionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic gooddirections : string [0..1]Reason for ordering the medicine, vaccine or other therapeutic goodclinicalIndication : string [0..1]Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate usecomment : string [0..1]The way in which this instruction differs from the previous instructionchangeType : CodeableConcept [1..1]Identifies whether the change has already been made or is a recommendation that has not been madechangeStatus : CodeableConcept [1..1]Description of the change in the subject of care's medication item informationchangeDescription : string [0..1]The justification for the stated change in medicationchangeorRecommendationReason : string [0..1]A textual narrative describing what the medication instruction is aboutnarrative : string [1..1]The date and, optionally, time after which the Medication Instruction is no longer effective or in forcedateTimeMedicationInstructionExpires : dateTime [1..1]AdverseReactionsAdverseReactionIdentification of a substance, agent, or a class of substance, that is considered to be responsible for the adverse reactionsubstanceAgent : CodeableConcept [1..1] « The set of values for the agent or substance causing the adverse reaction experienced by the subject of care. (Strength=Preferred)SubstanceAgentValues? »EventPresentation or exhibition of signs and symptoms of the adverse reaction expressed as a single word, phrase or brief descriptionmanifestation : CodeableConcept [1..*] « The set of values for recording clinical manifestation of an adverse reaction. (Strength=Preferred)ClinicalManifestationValues? »DiagnosticInvestigationsPathologyTestResultIdentification of the pathology test performed, sometimes including specimen typename : CodeableConcept [1..1]The diagnostic service that performs the examinationdiagnosticService : CodeableConcept [0..1]The status of the pathology test result as a wholeoverallPathologyTestResultStatus : CodeableConcept [1..1] « Set of values for the pathology test result status. (Strength=Required) PathologyTestResultStatusValu...! »Description or summary of relevant, prior clinical information that may help in determining the test(s) to be performed, or interpreting the result when compiling or reading the reportclinicalInformationProvided : string [0..1]Single word, phrase or brief description representing the diagnostic statement as asserted by the reporting pathologistpathologicalDiagnosis : CodeableConcept [0..*]Concise and clinically contextualised narrative interpretation of the pathology test resultspathologyTestConclusion : string [0..1]Rich text representation of the entire result as issued by the diagnostic servicerepresentation : base64Binary [0..1]Additional narrative about the test that is not captured in other fieldstestComment : string [0..1]Date, and optionally time, when an observation is clinically significant to the condition of the subject of the observationobservationDateTime : Period [1..1]SpecimenThe type of specimen to be collectedtissueType : CodeableConcept [0..1]The method of collection to be usedcollectionProcedure : CodeableConcept [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]PhysicalPropertiesofanObjectProperty of a body – commonly, but inadequately, defined as the quantity of matter in it – to which its inertia is ascribed, and expressed as the weight of the body divided by the acceleration due to gravityweight : Quantity [0..1]A description of other physical characteristics of the objectobjectDescription : string [0..1]A picture of the objectimage : base64Binary [0..1]DimensionsSize, measure or amount of anything in three dimensions; space occupied by a body or substance measured in cubic unitsvolume : Quantity [0..1]CollectionandHandlingAny conditions to be met before the sample should be takensamplingPreconditions : CodeableConcept [0..1]HandlingandProcessingThe date and time that the collection has been ordered to take place or has taken placecollectionDateTime : dateTime [1..1]Identification of the setting at which the specimen was collected from a subject of carecollectionSetting : string [0..1]The date and time that the sample was received at the laboratorydateTimeReceived : dateTime [0..1]IdentifiersUnique identifier of the specimen, normally assigned by the laboratoryspecimenIdentifier : Identifier [0..1]Unique identifier of the parent specimen where the specimen is split into sub-samplesparentSpecimenIdentifier : Identifier [0..1]Unique identifier given to the container in which the specimen is transported or processedcontainerIdentifier : Identifier [0..1]GroupThe name of a group of pathology test resultsname : CodeableConcept [1..1]IndividualPathologyTestResultThe name of an individual pathology test resultname : CodeableConcept [1..1]Comments that may include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the resultcomment : string [0..*]Additional advice on the applicability of the reference rangereferenceRangeGuidance : string [0..1]The status of the result valuestatus : CodeableConcept [1..1] « Set of values for the pathology test result status. (Strength=Required)PathologyTestResultStatusValu...! »ValueThe actual value of the resultvalue : CodeableConcept [1..1]ReferenceRangeDetailsAn indication of the degree of diagnostically significant abnormality of the value, based on available clinical information (including but not limited to the reference range)normalStatus : CodeableConcept [0..1]ReferenceRangeTerm whose value indicates the meaning of this rangemeaning : CodeableConcept [1..1]The data range for the associated Reference Range Meaning data element referenceRange : Range [0..1]SpecimenThe type of specimen to be collectedtissueType : CodeableConcept [0..1]The method of collection to be usedcollectionProcedure : CodeableConcept [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]PhysicalPropertiesofanObjectProperty of a body – commonly, but inadequately, defined as the quantity of matter in it – to which its inertia is ascribed, and expressed as the weight of the body divided by the acceleration due to gravityweight : Quantity [0..1]A description of other physical characteristics of the objectobjectDescription : string [0..1]A picture of the objectimage : base64Binary [0..1]DimensionsSize, measure or amount of anything in three dimensions; space occupied by a body or substance measured in cubic unitsvolume : Quantity [0..1]CollectionandHandlingAny conditions to be met before the sample should be takensamplingPreconditions : CodeableConcept [0..1]HandlingandProcessingThe date and time that the collection has been ordered to take place or has taken placecollectionDateTime : dateTime [1..1]Identification of the setting at which the specimen was collected from a subject of carecollectionSetting : string [0..1]The date and time that the sample was received at the laboratorydateTimeReceived : dateTime [0..1]IdentifiersUnique identifier of the specimen, normally assigned by the laboratoryspecimenIdentifier : Identifier [0..1]Unique identifier of the parent specimen where the specimen is split into sub-samplesparentSpecimenIdentifier : Identifier [0..1]Unique identifier given to the container in which the specimen is transported or processedcontainerIdentifier : Identifier [0..1]TestRequestDetailsIdentification of the pathology test which was requestedtestRequestedName : CodeableConcept [0..*]The identifier given to the laboratory test result of a pathology investigationlaboratoryTestResultIdentifier : Identifier [0..1]ImagingExaminationResultIdentification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)name : CodeableConcept [1..1]The imaging method used to perform the examinationimagingModality : CodeableConcept [0..1]The status of the examination result as a wholestatus : CodeableConcept [1..1] « Set of values for the imaging examination result status. (Strength=Required)ImagingExaminationResultStatu...! »Description of clinical information available at the time of interpretation of results, or a link to the original clinical information provided in the examination requestclinicalInformationProvided : string [0..1]Clinical assessment and opinion based on one or more observations and examinationsfindings : string [0..1]Rich text representation of the entire result as issued by the diagnostic servicerepresentation : base64Binary [0..1]Date, and optionally time, when an observation is clinically significant to the condition of the subject of the observationobservationDateTime : Period [1..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]GroupThe name of a group of structured resultsname : CodeableConcept [1..1]IndividualImagingExaminationResultThe name of a specific detailed resultname : CodeableConcept [1..1]May include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the resultresultComment : string [0..*]ValueThe actual value of the resultvalue : CodeableConcept [1..1]ReferenceRangeDetailsAn indication of the degree of diagnostically significant abnormality of the value, based on available clinical information (including but not limited to the reference range)normalStatus : CodeableConcept [0..1]ReferenceRangeTerm whose value indicates the meaning of this rangemeaning : CodeableConcept [1..1]The data range for the associated Reference Range Meaning data element referenceRange : Range [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]ExaminationRequestDetailsIdentification of the imaging examination which was requestedexaminationRequestedName : CodeableConcept [0..*]Unique identifier of this study allocated by the imaging servicedICOMStudyIdentifier : Identifier [0..1]The local identifier given to the imaging examination reportreportIdentifier : Identifier [0..1]ImageDetailsUnique identifier of this image allocated by the imaging serviceimageIdentifier : Identifier [0..1]Unique identifier of this series allocated by the imaging servicedICOMSeriesIdentifier : Identifier [0..1]The name of the imaging viewimageViewName : CodeableConcept [0..1]Description of the subject of care's position when the imaging examination was performedsubjectPosition : CodeableConcept [0..1]Date, and optionally time, the imaging examination was performedimageDateTime : dateTime [0..1]An attached or referenced image of a current viewimage : base64Binary [0..1]RequestedServiceDescribes the service arranged for, or provided to, the subject of caredescription : CodeableConcept [1..1]The date and, optionally, time at which the arranged service is scheduled to be provided to the subject of caredateTimeServiceScheduled : dateTime [0..1]The datetime or date range at or during which the arranged service is scheduled to be provided to the subject of carecommencementWindow : Period [0..1]An indication of the booking status of the arranged servicebookingStatus : CodeableConcept [1..1] « The set of values that indicate the booking status of the arranged service. (Strength=Required)ServiceBookingStatusValues! »Describes the instructions, advice or information that has been given to the subject of care from a healthcare provider in relation to the requested servicesubjectofCareInstructionDescription : string [0..1]The provider (individual or organisation) that has been arranged to provide the serviceprovider : Reference [0..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The point in time at which the Requested Service action is completeddateTime : dateTime [1..1]Encounter between a subject of care and a health systemencounter[1..1]Information about the subject of care problem or diagnosis as established by the specialistproblemDiagnosis[0..*]A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposesprocedure[0..*]Information about a subject of care problem or diagnosis established by the specialist; or procedure performed on the subject of care by the specialist. The information not available/captured as structured dataclinicalSynopsis[0..*]Information about a diagnosis and/or procedure as established/performed during or relevant to the specialist consultation not available as structured dataclinicalSynopsis2[1..1]A section that captures the main clinical outcome (diagnoses, procedures and narrative synopsis statement) about the response from the specialist following the referralresponseDetails[1..1]Recommendation by a clinician to a recipient health care provider regarding the management of the subject of carerecommendation[0..*]An explicit statement that no recommendation was madeexclusionStatement[0..1]A section that captures the recommendations by the referee/specialist to a recipient healthcare provider regarding the continuity of care and the ongoing management of the subject of carerecommendations[1..1]Statement to positively assert that the patient has not been prescribed or is not taking certain medicationexclusionStatementMedications[0..1]Information pertaining to one or more therapeutic goods that is represented to achieve, or is likely to achieve, its principal intended action by pharmacological, chemical, immunological or metabolic means in or on the body of a humanmedicationInstruction[0..*]A section that captures medication changes made and change recommendations regarding which medicines the subject of care should continue/commence/cease/alter relevant to and as a consequence of their interaction with the specialistmedicationOrders[1..1]Details about each adverse reaction eventevent[0..1]A harmful or undesirable effect associated with exposure to any substance or agentadverseReaction[1..*]Information about adverse reactions and/or propensity to adverse reaction of the subject of care (including allergies and intolerances), and any relevant reaction detailsadverseReactions[0..1]Specific and identified anatomical locationspecificLocation[0..1]The anatomical site from where the specimen was takenanatomicalLocation[0..*]The dimensions of the objectdimensions[0..1]Record of physical details, such as weight and dimensions, of a body part, device, lesion or specimenphysicalPropertiesofanObject[0..*]Collection and handling requirementscollectionandHandling[0..1]Workflow of specimen processing or handlinghandlingandProcessing[1..1]Sample identificationsidentifiers[0..1]Details about specimens to which this test result refersspecimen[1..*]A named range to be associated with any quantity datumreferenceRange[0..*]One or more reference ranges applicable to the Individual Pathology Test Result Value referenceRangeDetails[0..1]Value of the result, with reference range informationvalue[0..1]Specific detailed result of a pathology test, including both the value of the result item, and additional information that may be useful for clinical interpretationindividualPathologyTestResult[1..*]Specific and identified anatomical locationspecificLocation[0..1]The anatomical site from where the specimen was takenanatomicalLocation[0..*]The dimensions of the objectdimensions[0..1]Record of physical details, such as weight and dimensions, of a body part, device, lesion or specimenphysicalPropertiesofanObject[0..*]Collection and handling requirementscollectionandHandling[0..1]Workflow of specimen processing or handlinghandlingandProcessing[1..1]Sample identificationsidentifiers[0..1]Details about the individual specimen to which these result group test results refer, where testing of multiple specimens is requiredspecimen[0..1]A group of results that form all or part of a recognisable pathology testgroup[0..*]Details concerning a single requested pathology testtestRequestDetails[0..*]The result of a laboratory test which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' testspathologyTestResult[0..*]Specific and identified anatomical locationspecificLocation[0..1]Details about the anatomical locations to which this examination result refersanatomicalLocation[0..*]A named range to be associated with any quantity datumreferenceRange[0..*]One or more reference ranges applicable to the Imaging Examination Result Value referenceRangeDetails[0..1]Value of the result, with reference range informationvalue[0..1]Specific detailed result of an imaging examination, including both the value of the result item and additional information that may be useful for clinical interpretationindividualImagingExaminationResult[1..*]Specific and identified anatomical locationspecificLocation[0..1]Details about the individual anatomical location to which these result group examination results refer, where finer-grained representation of Anatomical Location is requiredanatomicalLocation[0..1]A group of structured resultsgroup[0..*]Images referenced or provided to assist clinical understanding of the examinationimageDetails[0..*]Details concerning a single requested examinationexaminationRequestDetails[0..*]The result of an imaging examination which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' testsimagingExaminationResult[0..*]A request for a diagnostic investigation of the subject of carerequestedService[0..*]Describes the diagnostic tests or procedures performed on or requested for the subject of care during the healthcare event, that are considered to be relevant to the subject of care’s ongoing carediagnosticInvestigations[0..1]

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. SpecialistLetter LogicalSpecialist Letter
... subjectofCare 1..1Reference(Patient)Subject of Care
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document Author
... encounter 1..1ElementEncounter
.... dateTimeHealthEventStarted 1..1dateTimeDateTime Health Event Started
... documentType 1..1IdentifierDocument Type
... usualGP 0..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Usual GP
... referrer 1..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Referrer
... dateTimeAttested 1..1dateTimeDateTime Attested
... responseDetails 1..1ElementResponse Details
.... problemDiagnosis 0..*ElementProblem/Diagnosis
..... identification 1..1CodeableConceptProblem/Diagnosis Identification
.... procedure 0..*ElementProcedure
..... name 1..1CodeableConceptProcedure Name
..... dateTime 1..1PeriodProcedure DateTime
.... clinicalSynopsis 0..*ElementClinical Synopsis
..... description 1..1stringClinical Synopsis Description
.... clinicalSynopsis2 1..1ElementClinical Synopsis
..... description 1..1stringClinical Synopsis Description
... recommendations 1..1ElementRecommendations
.... recommendation 0..*ElementRecommendation
..... addressee 1..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Addressee
..... timeFrame 1..1dateTimeRecommendation Time Frame
..... narrative 1..1stringRecommendation Narrative
.... exclusionStatement 0..1ElementExclusion Statement
..... generalStatement 1..1stringGeneral Statement
... medicationOrders 1..1ElementMedication Orders
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medications
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)
.... medicationInstruction 0..*ElementMedication Instruction
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)
..... directions 0..1stringDirections
..... clinicalIndication 0..1stringClinical Indication
..... comment 0..1stringMedication Instruction Comment
..... changeType 1..1CodeableConceptChange Type
..... changeStatus 1..1CodeableConceptChange Status
..... changeDescription 0..1stringChange Description
..... changeorRecommendationReason 0..1stringChange or Recommendation Reason
..... narrative 1..1stringMedication Instruction Narrative
..... dateTimeMedicationInstructionExpires 1..1dateTimeDateTime Medication Instruction Expires
... adverseReactions 0..1ElementAdverse Reactions
.... adverseReaction 1..*ElementAdverse Reaction
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)
..... event 0..1ElementReaction Event
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)
... diagnosticInvestigations 0..1ElementDiagnostic Investigations
.... pathologyTestResult 0..*ElementPathology Test Result
..... name 1..1CodeableConceptPathology Test Result Name
..... diagnosticService 0..1CodeableConceptDiagnostic Service
..... specimen 1..*ElementSpecimen
...... tissueType 0..1CodeableConceptSpecimen Tissue Type
...... collectionProcedure 0..1CodeableConceptCollection Procedure
...... anatomicalLocation 0..*ElementAnatomical Location
....... specificLocation 0..1ElementSpecific Location
........ anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
........ side 0..1CodeableConceptSide
....... description 0..1stringAnatomical Location Description
....... image 0..*base64BinaryAnatomical Location Image
...... physicalPropertiesofanObject 0..*ElementPhysical Properties of an Object
....... weight 0..1QuantityWeight
....... dimensions 0..1ElementDimensions
........ volume 0..1QuantityVolume
....... objectDescription 0..1stringObject Description
....... image 0..1base64BinaryImage
...... collectionandHandling 0..1ElementCollection and Handling
....... samplingPreconditions 0..1CodeableConceptSampling Preconditions
...... handlingandProcessing 1..1ElementHandling and Processing
....... collectionDateTime 1..1dateTimeCollection DateTime
....... collectionSetting 0..1stringCollection Setting
....... dateTimeReceived 0..1dateTimeDateTime Received
...... identifiers 0..1ElementIdentifiers
....... specimenIdentifier 0..1IdentifierSpecimen Identifier
....... parentSpecimenIdentifier 0..1IdentifierParent Specimen Identifier
....... containerIdentifier 0..1IdentifierContainer Identifier
..... overallPathologyTestResultStatus 1..1CodeableConceptOverall Pathology Test Result Status
PathologyTestResultStatusValues (Required)
..... clinicalInformationProvided 0..1stringClinical Information Provided
..... group 0..*ElementPathology Test Result Group
...... name 1..1CodeableConceptPathology Test Result Group Name
...... individualPathologyTestResult 1..*ElementIndividual Pathology Test Result
....... name 1..1CodeableConceptIndividual Pathology Test Result Name
....... value 0..1ElementIndividual Pathology Test Result Value
........ value 1..1CodeableConceptIndividual Pathology Test Result Value
........ referenceRangeDetails 0..1ElementReference Range Details
......... normalStatus 0..1CodeableConceptNormal Status
......... referenceRange 0..*ElementReference Range
.......... meaning 1..1CodeableConceptReference Range Meaning
.......... referenceRange 0..1RangeReference Range
....... comment 0..*stringIndividual Pathology Test Result Comment
....... referenceRangeGuidance 0..1stringIndividual Pathology Test Result Reference Range Guidance
....... status 1..1CodeableConceptIndividual Pathology Test Result Status
PathologyTestResultStatusValues (Required)
...... specimen 0..1ElementSpecimen
....... tissueType 0..1CodeableConceptSpecimen Tissue Type
....... collectionProcedure 0..1CodeableConceptCollection Procedure
....... anatomicalLocation 0..*ElementAnatomical Location
........ specificLocation 0..1ElementSpecific Location
......... anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
......... side 0..1CodeableConceptSide
........ description 0..1stringAnatomical Location Description
........ image 0..*base64BinaryAnatomical Location Image
....... physicalPropertiesofanObject 0..*ElementPhysical Properties of an Object
........ weight 0..1QuantityWeight
........ dimensions 0..1ElementDimensions
......... volume 0..1QuantityVolume
........ objectDescription 0..1stringObject Description
........ image 0..1base64BinaryImage
....... collectionandHandling 0..1ElementCollection and Handling
........ samplingPreconditions 0..1CodeableConceptSampling Preconditions
....... handlingandProcessing 1..1ElementHandling and Processing
........ collectionDateTime 1..1dateTimeCollection DateTime
........ collectionSetting 0..1stringCollection Setting
........ dateTimeReceived 0..1dateTimeDateTime Received
....... identifiers 0..1ElementIdentifiers
........ specimenIdentifier 0..1IdentifierSpecimen Identifier
........ parentSpecimenIdentifier 0..1IdentifierParent Specimen Identifier
........ containerIdentifier 0..1IdentifierContainer Identifier
..... pathologicalDiagnosis 0..*CodeableConceptPathological Diagnosis
..... pathologyTestConclusion 0..1stringPathology Test Conclusion
..... representation 0..1base64BinaryTest Result Representation
..... testComment 0..1stringTest Comment
..... testRequestDetails 0..*ElementTest Request Details
...... testRequestedName 0..*CodeableConceptTest Requested Name
...... laboratoryTestResultIdentifier 0..1IdentifierLaboratory Test Result Identifier
..... observationDateTime 1..1PeriodObservation DateTime
.... imagingExaminationResult 0..*ElementImaging Examination Result
..... name 1..1CodeableConceptImaging Examination Result Name
..... imagingModality 0..1CodeableConceptImaging Modality
..... anatomicalLocation 0..*ElementAnatomical Location
...... specificLocation 0..1ElementSpecific Location
....... anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
....... side 0..1CodeableConceptSide
...... description 0..1stringAnatomical Location Description
...... image 0..*base64BinaryAnatomical Location Image
..... status 1..1CodeableConceptImaging Examination Result Status
ImagingExaminationResultStatusValues (Required)
..... clinicalInformationProvided 0..1stringClinical Information Provided
..... findings 0..1stringFindings
..... group 0..*ElementImaging Examination Result Group
...... name 1..1CodeableConceptImaging Examination Result Group Name
...... individualImagingExaminationResult 1..*ElementIndividual Imaging Examination Result
....... name 1..1CodeableConceptIndividual Imaging Examination Result Name
....... value 0..1ElementImaging Examination Result Value
........ value 1..1CodeableConceptImaging Examination Result Value
........ referenceRangeDetails 0..1ElementReference Range Details
......... normalStatus 0..1CodeableConceptNormal Status
......... referenceRange 0..*ElementReference Range
.......... meaning 1..1CodeableConceptReference Range Meaning
.......... referenceRange 0..1RangeReference Range
....... resultComment 0..*stringResult Comment
...... anatomicalLocation 0..1ElementAnatomical Location
....... specificLocation 0..1ElementSpecific Location
........ anatomicalLocationName 0..1CodeableConceptAnatomical Location Name
........ side 0..1CodeableConceptSide
....... description 0..1stringAnatomical Location Description
....... image 0..*base64BinaryAnatomical Location Image
..... representation 0..1base64BinaryExamination Result Representation
..... examinationRequestDetails 0..*ElementExamination Request Details
...... examinationRequestedName 0..*CodeableConceptExamination Requested Name
...... dICOMStudyIdentifier 0..1IdentifierDICOM Study Identifier
...... reportIdentifier 0..1IdentifierReport Identifier
...... imageDetails 0..*ElementImage Details
....... imageIdentifier 0..1IdentifierImage Identifier
....... dICOMSeriesIdentifier 0..1IdentifierDICOM Series Identifier
....... imageViewName 0..1CodeableConceptImage View Name
....... subjectPosition 0..1CodeableConceptSubject Position
....... imageDateTime 0..1dateTimeImage DateTime
....... image 0..1base64BinaryImage
..... observationDateTime 1..1PeriodObservation DateTime
.... requestedService 0..*ElementRequested Service
..... description 1..1CodeableConceptRequested Service Description
..... dateTimeServiceScheduled 0..1dateTimeDateTime Service Scheduled
..... commencementWindow 0..1PeriodService Commencement Window
..... bookingStatus 1..1CodeableConceptService Booking Status
ServiceBookingStatusValues (Required)
..... subjectofCareInstructionDescription 0..1stringSubject of Care Instruction Description
..... provider 0..1Reference(Patient | Practitioner | Device | Organization | RelatedPerson)Service Provider
..... dateTime 1..1dateTimeRequested Service DateTime

doco Documentation for this format

UML Diagram

SpecialistLetter (Logical)Identification information about the patient that has been referred and is the subject of this specialist lettersubjectofCare : Reference [1..1] « Patient »The healthcare provider who is the source of this specialist letterdocumentAuthor : Reference [1..1] « Patient|Practitioner| RelatedPerson|Device »The NEHTA OID for the document exchange scenario(s) - i.e. the type of document - represented by this Structured Document. This is a fixed value (1.2.36.1.2001.1001.101.100.16615) for all instances of a Specialist Letter composition. Type of documentdocumentType : Identifier [1..1]A healthcare provider (person or organisation) nominated by the subject of care as being primarily responsible for their ongoing healthcareusualGP : Reference [0..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The healthcare provider from whom the subject of care was referred to this specialistreferrer : Reference [1..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The date (and time if known) that the document author or document authoriser/approver confirms (usually by signature) that a document is complete and genuinedateTimeAttested : dateTime [1..1]EncounterThe date and time when the specialist consultation took placedateTimeHealthEventStarted : dateTime [1..1]ResponseDetailsProblemDiagnosisIdentification of the problem or diagnosisidentification : CodeableConcept [1..1]ProcedureThe name of the procedure (to be) performedname : CodeableConcept [1..1]Date, and optionally time, of the Procedure actiondateTime : Period [1..1]ClinicalSynopsisShort description, overview or summary of a clinical event and its reasonsdescription : string [1..1]ClinicalSynopsis2Short description, overview or summary of a clinical event and its reasonsdescription : string [1..1]RecommendationsRecommendationThe intended recipient of the recommendationaddressee : Reference [1..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The time or time period for which the recommendation appliestimeFrame : dateTime [1..1]A textual narrative describing what the recommendation instruction is aboutnarrative : string [1..1]ExclusionStatementA general statement about the absence or exclusion of data valuesgeneralStatement : string [1..1]MedicationOrdersExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the statement about the absence or exclusion. (Strength=Required)GlobalStatementValues! »MedicationInstructionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic gooddirections : string [0..1]Reason for ordering the medicine, vaccine or other therapeutic goodclinicalIndication : string [0..1]Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate usecomment : string [0..1]The way in which this instruction differs from the previous instructionchangeType : CodeableConcept [1..1]Identifies whether the change has already been made or is a recommendation that has not been madechangeStatus : CodeableConcept [1..1]Description of the change in the subject of care's medication item informationchangeDescription : string [0..1]The justification for the stated change in medicationchangeorRecommendationReason : string [0..1]A textual narrative describing what the medication instruction is aboutnarrative : string [1..1]The date and, optionally, time after which the Medication Instruction is no longer effective or in forcedateTimeMedicationInstructionExpires : dateTime [1..1]AdverseReactionsAdverseReactionIdentification of a substance, agent, or a class of substance, that is considered to be responsible for the adverse reactionsubstanceAgent : CodeableConcept [1..1] « The set of values for the agent or substance causing the adverse reaction experienced by the subject of care. (Strength=Preferred)SubstanceAgentValues? »EventPresentation or exhibition of signs and symptoms of the adverse reaction expressed as a single word, phrase or brief descriptionmanifestation : CodeableConcept [1..*] « The set of values for recording clinical manifestation of an adverse reaction. (Strength=Preferred)ClinicalManifestationValues? »DiagnosticInvestigationsPathologyTestResultIdentification of the pathology test performed, sometimes including specimen typename : CodeableConcept [1..1]The diagnostic service that performs the examinationdiagnosticService : CodeableConcept [0..1]The status of the pathology test result as a wholeoverallPathologyTestResultStatus : CodeableConcept [1..1] « Set of values for the pathology test result status. (Strength=Required) PathologyTestResultStatusValu...! »Description or summary of relevant, prior clinical information that may help in determining the test(s) to be performed, or interpreting the result when compiling or reading the reportclinicalInformationProvided : string [0..1]Single word, phrase or brief description representing the diagnostic statement as asserted by the reporting pathologistpathologicalDiagnosis : CodeableConcept [0..*]Concise and clinically contextualised narrative interpretation of the pathology test resultspathologyTestConclusion : string [0..1]Rich text representation of the entire result as issued by the diagnostic servicerepresentation : base64Binary [0..1]Additional narrative about the test that is not captured in other fieldstestComment : string [0..1]Date, and optionally time, when an observation is clinically significant to the condition of the subject of the observationobservationDateTime : Period [1..1]SpecimenThe type of specimen to be collectedtissueType : CodeableConcept [0..1]The method of collection to be usedcollectionProcedure : CodeableConcept [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]PhysicalPropertiesofanObjectProperty of a body – commonly, but inadequately, defined as the quantity of matter in it – to which its inertia is ascribed, and expressed as the weight of the body divided by the acceleration due to gravityweight : Quantity [0..1]A description of other physical characteristics of the objectobjectDescription : string [0..1]A picture of the objectimage : base64Binary [0..1]DimensionsSize, measure or amount of anything in three dimensions; space occupied by a body or substance measured in cubic unitsvolume : Quantity [0..1]CollectionandHandlingAny conditions to be met before the sample should be takensamplingPreconditions : CodeableConcept [0..1]HandlingandProcessingThe date and time that the collection has been ordered to take place or has taken placecollectionDateTime : dateTime [1..1]Identification of the setting at which the specimen was collected from a subject of carecollectionSetting : string [0..1]The date and time that the sample was received at the laboratorydateTimeReceived : dateTime [0..1]IdentifiersUnique identifier of the specimen, normally assigned by the laboratoryspecimenIdentifier : Identifier [0..1]Unique identifier of the parent specimen where the specimen is split into sub-samplesparentSpecimenIdentifier : Identifier [0..1]Unique identifier given to the container in which the specimen is transported or processedcontainerIdentifier : Identifier [0..1]GroupThe name of a group of pathology test resultsname : CodeableConcept [1..1]IndividualPathologyTestResultThe name of an individual pathology test resultname : CodeableConcept [1..1]Comments that may include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the resultcomment : string [0..*]Additional advice on the applicability of the reference rangereferenceRangeGuidance : string [0..1]The status of the result valuestatus : CodeableConcept [1..1] « Set of values for the pathology test result status. (Strength=Required)PathologyTestResultStatusValu...! »ValueThe actual value of the resultvalue : CodeableConcept [1..1]ReferenceRangeDetailsAn indication of the degree of diagnostically significant abnormality of the value, based on available clinical information (including but not limited to the reference range)normalStatus : CodeableConcept [0..1]ReferenceRangeTerm whose value indicates the meaning of this rangemeaning : CodeableConcept [1..1]The data range for the associated Reference Range Meaning data element referenceRange : Range [0..1]SpecimenThe type of specimen to be collectedtissueType : CodeableConcept [0..1]The method of collection to be usedcollectionProcedure : CodeableConcept [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]PhysicalPropertiesofanObjectProperty of a body – commonly, but inadequately, defined as the quantity of matter in it – to which its inertia is ascribed, and expressed as the weight of the body divided by the acceleration due to gravityweight : Quantity [0..1]A description of other physical characteristics of the objectobjectDescription : string [0..1]A picture of the objectimage : base64Binary [0..1]DimensionsSize, measure or amount of anything in three dimensions; space occupied by a body or substance measured in cubic unitsvolume : Quantity [0..1]CollectionandHandlingAny conditions to be met before the sample should be takensamplingPreconditions : CodeableConcept [0..1]HandlingandProcessingThe date and time that the collection has been ordered to take place or has taken placecollectionDateTime : dateTime [1..1]Identification of the setting at which the specimen was collected from a subject of carecollectionSetting : string [0..1]The date and time that the sample was received at the laboratorydateTimeReceived : dateTime [0..1]IdentifiersUnique identifier of the specimen, normally assigned by the laboratoryspecimenIdentifier : Identifier [0..1]Unique identifier of the parent specimen where the specimen is split into sub-samplesparentSpecimenIdentifier : Identifier [0..1]Unique identifier given to the container in which the specimen is transported or processedcontainerIdentifier : Identifier [0..1]TestRequestDetailsIdentification of the pathology test which was requestedtestRequestedName : CodeableConcept [0..*]The identifier given to the laboratory test result of a pathology investigationlaboratoryTestResultIdentifier : Identifier [0..1]ImagingExaminationResultIdentification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)name : CodeableConcept [1..1]The imaging method used to perform the examinationimagingModality : CodeableConcept [0..1]The status of the examination result as a wholestatus : CodeableConcept [1..1] « Set of values for the imaging examination result status. (Strength=Required)ImagingExaminationResultStatu...! »Description of clinical information available at the time of interpretation of results, or a link to the original clinical information provided in the examination requestclinicalInformationProvided : string [0..1]Clinical assessment and opinion based on one or more observations and examinationsfindings : string [0..1]Rich text representation of the entire result as issued by the diagnostic servicerepresentation : base64Binary [0..1]Date, and optionally time, when an observation is clinically significant to the condition of the subject of the observationobservationDateTime : Period [1..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]GroupThe name of a group of structured resultsname : CodeableConcept [1..1]IndividualImagingExaminationResultThe name of a specific detailed resultname : CodeableConcept [1..1]May include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the resultresultComment : string [0..*]ValueThe actual value of the resultvalue : CodeableConcept [1..1]ReferenceRangeDetailsAn indication of the degree of diagnostically significant abnormality of the value, based on available clinical information (including but not limited to the reference range)normalStatus : CodeableConcept [0..1]ReferenceRangeTerm whose value indicates the meaning of this rangemeaning : CodeableConcept [1..1]The data range for the associated Reference Range Meaning data element referenceRange : Range [0..1]AnatomicalLocationDescription of the anatomical locationdescription : string [0..1]An image or images used to identify a locationimage : base64Binary [0..*]SpecificLocationThe name of the anatomical locationanatomicalLocationName : CodeableConcept [0..1]The laterality of the anatomical locationside : CodeableConcept [0..1]ExaminationRequestDetailsIdentification of the imaging examination which was requestedexaminationRequestedName : CodeableConcept [0..*]Unique identifier of this study allocated by the imaging servicedICOMStudyIdentifier : Identifier [0..1]The local identifier given to the imaging examination reportreportIdentifier : Identifier [0..1]ImageDetailsUnique identifier of this image allocated by the imaging serviceimageIdentifier : Identifier [0..1]Unique identifier of this series allocated by the imaging servicedICOMSeriesIdentifier : Identifier [0..1]The name of the imaging viewimageViewName : CodeableConcept [0..1]Description of the subject of care's position when the imaging examination was performedsubjectPosition : CodeableConcept [0..1]Date, and optionally time, the imaging examination was performedimageDateTime : dateTime [0..1]An attached or referenced image of a current viewimage : base64Binary [0..1]RequestedServiceDescribes the service arranged for, or provided to, the subject of caredescription : CodeableConcept [1..1]The date and, optionally, time at which the arranged service is scheduled to be provided to the subject of caredateTimeServiceScheduled : dateTime [0..1]The datetime or date range at or during which the arranged service is scheduled to be provided to the subject of carecommencementWindow : Period [0..1]An indication of the booking status of the arranged servicebookingStatus : CodeableConcept [1..1] « The set of values that indicate the booking status of the arranged service. (Strength=Required)ServiceBookingStatusValues! »Describes the instructions, advice or information that has been given to the subject of care from a healthcare provider in relation to the requested servicesubjectofCareInstructionDescription : string [0..1]The provider (individual or organisation) that has been arranged to provide the serviceprovider : Reference [0..1] « Patient|Practitioner|Device| Organization|RelatedPerson »The point in time at which the Requested Service action is completeddateTime : dateTime [1..1]Encounter between a subject of care and a health systemencounter[1..1]Information about the subject of care problem or diagnosis as established by the specialistproblemDiagnosis[0..*]A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposesprocedure[0..*]Information about a subject of care problem or diagnosis established by the specialist; or procedure performed on the subject of care by the specialist. The information not available/captured as structured dataclinicalSynopsis[0..*]Information about a diagnosis and/or procedure as established/performed during or relevant to the specialist consultation not available as structured dataclinicalSynopsis2[1..1]A section that captures the main clinical outcome (diagnoses, procedures and narrative synopsis statement) about the response from the specialist following the referralresponseDetails[1..1]Recommendation by a clinician to a recipient health care provider regarding the management of the subject of carerecommendation[0..*]An explicit statement that no recommendation was madeexclusionStatement[0..1]A section that captures the recommendations by the referee/specialist to a recipient healthcare provider regarding the continuity of care and the ongoing management of the subject of carerecommendations[1..1]Statement to positively assert that the patient has not been prescribed or is not taking certain medicationexclusionStatementMedications[0..1]Information pertaining to one or more therapeutic goods that is represented to achieve, or is likely to achieve, its principal intended action by pharmacological, chemical, immunological or metabolic means in or on the body of a humanmedicationInstruction[0..*]A section that captures medication changes made and change recommendations regarding which medicines the subject of care should continue/commence/cease/alter relevant to and as a consequence of their interaction with the specialistmedicationOrders[1..1]Details about each adverse reaction eventevent[0..1]A harmful or undesirable effect associated with exposure to any substance or agentadverseReaction[1..*]Information about adverse reactions and/or propensity to adverse reaction of the subject of care (including allergies and intolerances), and any relevant reaction detailsadverseReactions[0..1]Specific and identified anatomical locationspecificLocation[0..1]The anatomical site from where the specimen was takenanatomicalLocation[0..*]The dimensions of the objectdimensions[0..1]Record of physical details, such as weight and dimensions, of a body part, device, lesion or specimenphysicalPropertiesofanObject[0..*]Collection and handling requirementscollectionandHandling[0..1]Workflow of specimen processing or handlinghandlingandProcessing[1..1]Sample identificationsidentifiers[0..1]Details about specimens to which this test result refersspecimen[1..*]A named range to be associated with any quantity datumreferenceRange[0..*]One or more reference ranges applicable to the Individual Pathology Test Result Value referenceRangeDetails[0..1]Value of the result, with reference range informationvalue[0..1]Specific detailed result of a pathology test, including both the value of the result item, and additional information that may be useful for clinical interpretationindividualPathologyTestResult[1..*]Specific and identified anatomical locationspecificLocation[0..1]The anatomical site from where the specimen was takenanatomicalLocation[0..*]The dimensions of the objectdimensions[0..1]Record of physical details, such as weight and dimensions, of a body part, device, lesion or specimenphysicalPropertiesofanObject[0..*]Collection and handling requirementscollectionandHandling[0..1]Workflow of specimen processing or handlinghandlingandProcessing[1..1]Sample identificationsidentifiers[0..1]Details about the individual specimen to which these result group test results refer, where testing of multiple specimens is requiredspecimen[0..1]A group of results that form all or part of a recognisable pathology testgroup[0..*]Details concerning a single requested pathology testtestRequestDetails[0..*]The result of a laboratory test which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' testspathologyTestResult[0..*]Specific and identified anatomical locationspecificLocation[0..1]Details about the anatomical locations to which this examination result refersanatomicalLocation[0..*]A named range to be associated with any quantity datumreferenceRange[0..*]One or more reference ranges applicable to the Imaging Examination Result Value referenceRangeDetails[0..1]Value of the result, with reference range informationvalue[0..1]Specific detailed result of an imaging examination, including both the value of the result item and additional information that may be useful for clinical interpretationindividualImagingExaminationResult[1..*]Specific and identified anatomical locationspecificLocation[0..1]Details about the individual anatomical location to which these result group examination results refer, where finer-grained representation of Anatomical Location is requiredanatomicalLocation[0..1]A group of structured resultsgroup[0..*]Images referenced or provided to assist clinical understanding of the examinationimageDetails[0..*]Details concerning a single requested examinationexaminationRequestDetails[0..*]The result of an imaging examination which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' testsimagingExaminationResult[0..*]A request for a diagnostic investigation of the subject of carerequestedService[0..*]Describes the diagnostic tests or procedures performed on or requested for the subject of care during the healthcare event, that are considered to be relevant to the subject of care’s ongoing carediagnosticInvestigations[0..1]

 

??.??.4.1 Terminology Bindings

PathDefinitionTypeReference
SpecialistLetter.responseDetails.problemDiagnosis.identification The Problem/Diagnosis reference set provides terminology to support the recording of a subject of care problem or diagnosis for medical records within Australia.UnknownNo details provided yet
SpecialistLetter.responseDetails.procedure.name The Procedure foundation reference set provides the broadest possible terminology to support the recording of clinical interventions in Australian eHealth implementations.UnknownNo details provided yet
SpecialistLetter.medicationOrders.exclusionStatementMedications.globalStatement The set of values for the statement about the absence or exclusion.RequiredGlobalStatementValues
SpecialistLetter.medicationOrders.medicationInstruction.therapeuticGoodIdentification A set of values used to refer to medicines and other therapeutic goods.PreferredMedicinesTerminology
SpecialistLetter.medicationOrders.medicationInstruction.changeType The set of values for Change Type .UnknownNo details provided yet
SpecialistLetter.medicationOrders.medicationInstruction.changeStatus The set of values for Change Status .UnknownNo details provided yet
SpecialistLetter.adverseReactions.adverseReaction.substanceAgent The set of values for the agent or substance causing the adverse reaction experienced by the subject of care.PreferredSubstanceAgentValues
SpecialistLetter.adverseReactions.adverseReaction.event.manifestation The set of values for recording clinical manifestation of an adverse reaction.PreferredClinicalManifestationValues
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.name
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.name
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.testRequestDetails.testRequestedName 		Set of values for the names of pathology tests requested or performed.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.diagnosticService Set of values for the type of diagnostic service.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.specimen.tissueType
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.specimen.tissueType 		The set of values for the categorisation of the sample taken from an individual and submitted for pathology investigation.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.specimen.collectionProcedure
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.specimen.collectionProcedure 		The set of values for the method of collection to be used, e.g. venepuncture, biopsy, resection.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.specimen.anatomicalLocation.specificLocation.anatomicalLocationName
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.specimen.anatomicalLocation.specificLocation.anatomicalLocationName
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.anatomicalLocation.specificLocation.anatomicalLocationName
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.anatomicalLocation.specificLocation.anatomicalLocationName 		The set of values for named anatomical locations.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.specimen.anatomicalLocation.specificLocation.side
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.specimen.anatomicalLocation.specificLocation.side
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.anatomicalLocation.specificLocation.side
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.anatomicalLocation.specificLocation.side 		The set of values for identifying the laterality of an anatomical location.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.specimen.collectionandHandling.samplingPreconditions
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.specimen.collectionandHandling.samplingPreconditions 		The set of values for any conditions to be met before the sample should be taken e.g. fasting, 'full bladder', 'sterile field' or any special instructions on the handling or immediate processing of the sample e.g. centrifuge on receipt.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.overallPathologyTestResultStatus
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.individualPathologyTestResult.status 		Set of values for the pathology test result status.RequiredPathologyTestResultStatusValues
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.individualPathologyTestResult.name Set of values for the names of individual pathology tests performed.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.individualPathologyTestResult.value.value
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.individualImagingExaminationResult.value.value 		Set of values for Pathology Test Result Value .UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.individualPathologyTestResult.value.referenceRangeDetails.normalStatus
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.individualImagingExaminationResult.value.referenceRangeDetails.normalStatus 		UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.group.individualPathologyTestResult.value.referenceRangeDetails.referenceRange.meaning
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.individualImagingExaminationResult.value.referenceRangeDetails.referenceRange.meaning 		UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.pathologyTestResult.pathologicalDiagnosis UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.name
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.individualImagingExaminationResult.name 		A terminology for Examination Result name, potientially pre-coordinated terms specifying both modality and anatomical location. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.imagingModality Values of imaging method, e.g. Ultrasound, CT, X-ray.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.status Set of values for the imaging examination result status.RequiredImagingExaminationResultStatusValues
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.group.name Results may be grouped by anatomical location or by some other name or code to describe what binds all the results together. If a name or code is used, it is provided by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Should be coded with LOINC or SNOMED CT.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.examinationRequestDetails.examinationRequestedName UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.examinationRequestDetails.imageDetails.imageViewName The set of values for the description of the view taken.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.imagingExaminationResult.examinationRequestDetails.imageDetails.subjectPosition UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.requestedService.description The set of values for the service arranged for, or provided to, the patient.UnknownNo details provided yet
SpecialistLetter.diagnosticInvestigations.requestedService.bookingStatus The set of values that indicate the booking status of the arranged service.RequiredServiceBookingStatusValues

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