This page is part of the Data Access Framework (v1.6.0: STU 2 Ballot 1) based on FHIR v1.6.0. . For a full list of available versions, see the Directory of published versions
Definitions for the daf-core-diagnosticreport Profile.
DiagnosticReport(DAFCoreDiagnosticReport) | |
Definition | The scope is accessing a diagnostic report. |
Control | 0..* |
Alternate Names | Report, Test, Result, Results, Labs, Laboratory, Lab Result, Lab Report |
Comments | This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. |
Invariants | Defined on this element dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (xpath: not(parent::f:contained and f:text)) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (xpath: not(parent::f:contained and f:contained)) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (xpath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (xpath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))) |
DiagnosticReport.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
DiagnosticReport.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
Control | 0..1 |
Type | Meta |
DiagnosticReport.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible. |
DiagnosticReport.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language. The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable |
Type | code |
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
DiagnosticReport.text | |
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later. |
DiagnosticReport.contained | |
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. |
DiagnosticReport.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
DiagnosticReport.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
DiagnosticReport.identifier | |
Definition | The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider. |
Note | This is a business identifer, not a resource identifier (see discussion) |
Control | 0..* |
Type | Identifier |
Requirements | Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. |
Alternate Names | ReportID |
DiagnosticReport.status | |
Definition | The status of the diagnostic report as a whole. |
Control | 1..1 |
Binding | null The codes SHALL be taken from DiagnosticReportStatus |
Type | code |
Is Modifier | true |
Must Support | true |
Requirements | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. |
Comments | This is labeled as "Is Modifier" because applications need to take appropriate action if a report is withdrawn. |
DiagnosticReport.category | |
Definition | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. |
Control | 1..1 |
Binding | Codes for diagnostic service sections. For example codes, see Diagnostic Service Section Codes |
Type | CodeableConcept |
Must Support | true |
Alternate Names | Department, Sub-department, service, discipline |
Comments | The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. |
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://hl7.org/fhir/DiagnosticReport-category"/> <code value="LAB"/> </coding> </valueCodeableConcept> |
DiagnosticReport.code | |
Definition | The test, panel or battery that was ordered. |
Control | 1..1 |
Binding | LOINC codes The codes SHALL be taken from LOINC Diagnostic Report Codes; other codes may be used where these codes are not suitable |
Type | CodeableConcept |
Must Support | true |
Comments | UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists. |
DiagnosticReport.subject | |
Definition | The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources. |
Control | 1..1 |
Type | Reference(Profile daf-core-patient) |
Must Support | true |
Requirements | SHALL know the subject context. |
Alternate Names | Patient |
DiagnosticReport.encounter | |
Definition | The link to the health care event (encounter) when the order was made. |
Control | 0..1 |
Type | Reference(Encounter) |
DiagnosticReport.effective[x] | |
Definition | This is the Specimen Collection Datetime or Period which is the physically relevent dateTime for laboratory tests. |
Control | 1..1 |
Type | Choice of: dateTime, Period |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Must Support | true |
Requirements | Need to know where in the patient history to file/present this report. |
Alternate Names | Observation time, Effective Time |
Comments | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. |
DiagnosticReport.issued | |
Definition | The date and time that this version of the report was released from the source diagnostic service. |
Control | 1..1 |
Type | instant |
Must Support | true |
Requirements | Clinicians need to be able to check the date that the report was released. |
Alternate Names | Date Created, Date published, Date Issued |
Comments | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. |
DiagnosticReport.performer | |
Definition | The diagnostic service that is responsible for issuing the report. |
Control | 1..1 |
Type | Choice of: Reference(Profile daf-core-pract), Reference(Profile daf-core-organization) |
Must Support | true |
Requirements | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. |
Alternate Names | Laboratory, Service, Practitioner, Department, Company |
Comments | This is not necessarily the source of the atomic data items. It is the entity that takes responsibility for the clinical report. |
DiagnosticReport.request | |
Definition | Details concerning a test or procedure requested. |
Control | 0..* |
Type | Choice of: Reference(DiagnosticRequest), Reference(ProcedureRequest), Reference(ReferralRequest) |
Requirements | Need to be able to track completion of requests based on reports issued and also to report what diagnostic tests were requested (not always the same as what is delivered). |
Comments | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. |
DiagnosticReport.specimen | |
Definition | Details about the specimens on which this diagnostic report is based. |
Control | 0..* |
Type | Reference(Specimen) |
Requirements | Need to be able to report information about the collected specimens on which the report is based. |
Comments | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per Observation or group. |
DiagnosticReport.result | |
Definition | Observations that are part of this diagnostic report. Observations can be simple name/value pairs (e.g. "atomic" results), or they can be grouping observations that include references to other members of the group (e.g. "panels"). |
Control | 1..* |
Type | Reference(Profile daf-core-resultobs) |
Must Support | true |
Requirements | Need to support individual results, or report groups of results, where the result grouping is arbitrary, but meaningful. This structure is recursive - observations can contain observations. |
Alternate Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer |
DiagnosticReport.imagingStudy | |
Definition | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. |
Control | 0..* |
Type | Choice of: Reference(ImagingStudy), Reference(ImagingManifest) |
Comments | ImagingStudy and ImageManifest and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. |
DiagnosticReport.image | |
Definition | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). |
Control | 0..* |
Type | BackboneElement |
Requirements | Many diagnostic services include images in the report as part of their service. |
Alternate Names | DICOM, Slides, Scans |
DiagnosticReport.image.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
DiagnosticReport.image.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
DiagnosticReport.image.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
DiagnosticReport.image.comment | |
Definition | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. |
Control | 0..1 |
Type | string |
Requirements | The provider of the report should make a comment about each image included in the report. |
Comments | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. |
DiagnosticReport.image.link | |
Definition | Reference to the image source. |
Control | 1..1 |
Type | Reference(Media) |
DiagnosticReport.conclusion | |
Definition | Concise and clinically contextualized impression / summary of the diagnostic report. |
Control | 0..1 |
Type | string |
Requirements | Need to be able to provide a conclusion that is not lost among the basic result data. |
Alternate Names | Report |
DiagnosticReport.codedDiagnosis | |
Definition | Codes for the conclusion. |
Control | 0..* |
Binding | Diagnoses codes provided as adjuncts to the report. For example codes, see SNOMED CT Clinical Findings |
Type | CodeableConcept |
DiagnosticReport.presentedForm | |
Definition | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. |
Control | 0..* |
Type | Attachment |
Requirements | Gives Laboratory the ability to provide its own fully formatted report for clinical fidelity. |
Comments | "application/pdf" is recommended as the most reliable and interoperable in this context. |