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US Core DiagnosticReport for Report and Note Exchange

Previous Page - US Core DiagnosticReport for Laboratory Results Reporting

Where a Health Plan has access to clinical notes and associated diagnostic information, they SHALL make the information available using the US Core DiagnosticReport for Report and Note Exchange resource.

The essential fields (Must Support or Cardinality greater than 0..*) to be provided in the US Core DiagnosticReport for Report and Note Exchange resource are:

Table Definition

Example DiagnosticReport for Report and Note exchange Resource

An example mapping of a DiagnosticReport for urinalysis is shown below:

{
  "resourceType" : "DiagnosticReport",
  "id" : "urinalysis",
  "meta" : {
    "versionId" : "209563",
    "lastUpdated" : "2016-04-19T17:28:11.308+00:00",
    "profile" : [
      "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">
Generated Narrative with Details
id: urinalysis
meta: 
status: final
category: Laboratory <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/v2-0074 code 'LAB' = 'Laboratory', given as 'Laboratory'})</span>
code: Complete Urinalysis <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '24356-8' = 'Urinalysis complete panel - Urine', given as 'Urinalysis complete panel - Urine'})</span>
subject: <a href=\"Patient-example.html\">Amy Shaw. Generated Summary: id: example; Medical Record Number = 1032702 (USUAL); active; Amy V. Shaw ; ph: 555-555-5555(HOME), amy.shaw@example.com; gender: female; birthDate: Feb 20, 2007</a>
effective: Jul 5, 2005, 12:00:00 AM
issued: Jul 6, 2005, 12:45:33 AM
performer: <a href=\"Organization-acme-lab.html\">Acme Laboratory, Inc. Generated Summary: id: acme-lab; 1144221847, 2523423456; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span>; name: Acme Labs; ph: (+1) 734-677-7777, hq@acme.org</a>
result: 
<a href=\"Observation-urine-color.html\">COLOR=Yellow. Generated Summary: id: urine-color; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5778-6}\">COLOR</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.inbnm,fo/sct 371244009}\">Yellow</span></a>
<a href=\"Observation-urine-clarity.html\">APPEARANCE=Hazy. Generated Summary: id: urine-clarity; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 32167-9}\">APPEARANCE</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 81858005}\">Hazy</span></a>
<a href=\"Observation-urine-glucose.html\">GLUCOSE=Negative. Generated Summary: id: urine-glucose; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 25428-4}\">GLUCOSE</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260385009}\">Negative</span></a>
<a href=\"Observation-urine-bilirubin.html\">BILIRUBIN=Negative. Generated Summary: id: urine-bilirubin; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5770-3}\">BILIRUBIN</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260385009}\">Negative</span></a>
<a href=\"Observation-urine-ketone.html\">KETONE=Negative. Generated Summary: id: urine-ketone; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 2514-8}\">KETONE</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260385009}\">Negative</span></a>
<a href=\"Observation-usg.html\">SPEC GRAV=1.017. Generated Summary: id: usg; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5811-5}\">SPEC GRAV</span>; effective: Jul 5, 2005, 12:00:00 AM; 1.017 {urine specific gravity}</a>
<a href=\"Observation-urine-ph.html\">PH=6 (pH). Generated Summary: id: urine-ph; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5803-2}\">PH</span>; effective: Jul 5, 2005, 12:00:00 AM; 6.0 (pH)</a>
<a href=\"Observation-urine-protein.html\">PROTEIN=Negative. Generated Summary: id: urine-protein; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 20454-5}\">PROTEIN</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260385009}\">Negative</span></a>
<a href=\"Observation-urobilinogen.html\">UROBILINOGEN=0.3 mg/dL. Generated Summary: id: urobilinogen; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 20405-7}\">UROBILINOGEN</span>; effective: Jul 5, 2005, 12:00:00 AM; 0.3 mg/dL</a>
<a href=\"Observation-urine-nitrite.html\">NITRITE=Positive. Generated Summary: id: urine-nitrite; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5802-4}\">NITRITE</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 10828004}\">Positive</span></a>
<a href=\"Observation-urine-hemoglobin.html\">BLOOD=Trace. Generated Summary: id: urine-hemoglobin; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5794-3}\">BLOOD</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260405006}\">Trace</span></a>
<a href=\"Observation-urine-leukocyte-esterase.html\">LEUK ESTERASE=2+e. Generated Summary: id: urine-leukocyte-esterase; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5799-2}\">LEUK ESTERASE</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260348001}\">2+</span></a>
<a href=\"Observation-urine-sediment.html\">COMMENT=Recommend Urine Culture. Generated Summary: id: urine-sediment; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 11279-7}\">COMMENT</span>; effective: Jul 5, 2005, 12:00:00 AM; value: Recommend Urine Culture</a>
<a href=\"Observation-urine-bacteria.html\">BACTERIA=4+. Generated Summary: id: urine-bacteria; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 25145-4}\">BACTERIA</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 260350009}\">4+</span></a>
<a href=\"Observation-urine-epi-cells.html\">EPITHELIAL CELLS=1-5 cells/HPF. Generated Summary: id: urine-epi-cells; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5787-7}\">EPITHELIAL CELLS</span>; effective: Jul 5, 2005, 12:00:00 AM; </a>
<a href=\"Observation-urine-wbcs.html\">WBC=20-30 cells/HPF. Generated Summary: id: urine-wbcs; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 5821-4}\">WBC</span>; effective: Jul 5, 2005, 12:00:00 AM; </a>
<a href=\"Observation-urine-rbcs.html\">RBC=Occasional cells/HPF. Generated Summary: id: urine-rbcs; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span>; <span title=\"Codes: {http://loinc.org 13945-1}\">RBC</span>; effective: Jul 5, 2005, 12:00:00 AM; <span title=\"Codes: {http://snomed.info/sct 84638005}\">Occasional</span></a>
</div>"
  },
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "LAB",
          "display" : "Laboratory"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "24356-8",
        "display" : "Urinalysis complete panel - Urine"
      }
    ],
    "text" : "Complete Urinalysis"
  },
  "subject" : {
    "reference" : "Patient/example",
    "display" : "Amy Shaw"
  },
  "effectiveDateTime" : "2005-07-05",
  "issued" : "2005-07-06T11:45:33+11:00",
  "performer" : [
    {
      "reference" : "Organization/acme-lab",
      "display" : "Acme Laboratory, Inc"
    }
  ],
  "result" : [
    {
      "reference" : "Observation/urine-color",
      "display" : "COLOR=Yellow"
    },
    {
      "reference" : "Observation/urine-clarity",
      "display" : "APPEARANCE=Hazy"
    },
    {
      "reference" : "Observation/urine-glucose",
      "display" : "GLUCOSE=Negative"
    },
    {
      "reference" : "Observation/urine-bilirubin",
      "display" : "BILIRUBIN=Negative"
    },
    {
      "reference" : "Observation/urine-ketone",
      "display" : "KETONE=Negative"
    },
    {
      "reference" : "Observation/usg",
      "display" : "SPEC GRAV=1.017"
    },
    {
      "reference" : "Observation/urine-ph",
      "display" : "PH=6 (pH)"
    },
    {
      "reference" : "Observation/urine-protein",
      "display" : "PROTEIN=Negative"
    },
    {
      "reference" : "Observation/urobilinogen",
      "display" : "UROBILINOGEN=0.3 mg/dL"
    },
    {
      "reference" : "Observation/urine-nitrite",
      "display" : "NITRITE=Positive"
    },
    {
      "reference" : "Observation/urine-hemoglobin",
      "display" : "BLOOD=Trace"
    },
    {
      "reference" : "Observation/urine-leukocyte-esterase",
      "display" : "LEUK ESTERASE=2+e"
    },
    {
      "reference" : "Observation/urine-sediment",
      "display" : "COMMENT=Recommend Urine Culture"
    },
    {
      "reference" : "Observation/urine-bacteria",
      "display" : "BACTERIA=4+"
    },
    {
      "reference" : "Observation/urine-epi-cells",
      "display" : "EPITHELIAL CELLS=1-5 cells/HPF"
    },
    {
      "reference" : "Observation/urine-wbcs",
      "display" : "WBC=20-30 cells/HPF"
    },
    {
      "reference" : "Observation/urine-rbcs",
      "display" : "RBC=Occasional cells/HPF"
    }
  ]
}

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