This page is part of the Da Vinci Payer Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

3-6-11 US Core DiagnosticReport

Where a Health Plan has access to Laboratory Results and other diagnostic information they SHALL make the information available using the US Core DiagnosticReport resource.

The essential fields to be provided in the US Core DiagnosticReport resource are:

R4 Hierarchical Name	R4 Name	Card.	Type
DiagnosticReport	DiagnosticReport	0..*
DiagnosticReport.id	id	0..1	id
DiagnosticReport.status	status	1..1	code
DiagnosticReport.category	category	1..1	CodeableConcept
DiagnosticReport.code	code	1..1	CodeableConcept
DiagnosticReport.subject	subject	1..1	Reference(US Core Patient Profile)
DiagnosticReport.effective[x]	effective[x]	1..1	dateTime, Period
DiagnosticReport.issued	issued	1..1	instant
DiagnosticReport.performer	performer	0..*	Reference(US Core Practitioner Profile	US Core Organization Profile)
DiagnosticReport.result	result	0..*	Reference(US Core Result Observation Profile)
DiagnosticReport.media	media	0..*	BackboneElement
DiagnosticReport.presentedForm	presentedForm	0..*	Attachment

3-6-11-1 Example DiagnosticReport 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"
    }
  ]
}