DiagnosticReport - FHIR v0.0.82

This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.16.7 Resource DiagnosticReport - Formal Definitions

Formal definitions for the elements in the DiagnosticReport resource.

DiagnosticReport
Definition	The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretation, and formatted representation of diagnostic reports.
Control	1..1
Requirements	To support reporting for any diagnostic report into a clinical data repository.
Aliases	Report; Test; Result; Results; Labs; Laboratory
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.
DiagnosticReport.name
Definition	A code or name that describes this diagnostic report.
Control	1..1
Binding	DiagnosticReportNames: LOINC Codes for Diagnostic Reports (See http://hl7.org/fhir/vs/report-names)
Type	CodeableConcept
DiagnosticReport.status
Definition	The status of the diagnostic report as a whole.
Control	1..1
Binding	DiagnosticReportStatus: The status of the diagnostic report as a whole (see http://hl7.org/fhir/diagnostic-report-status for values)
Type	code
Is Modifier	true
Requirements	Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Summary	true
Comments	This is labeled as "Is Modifier" because applications need to take appropriate action if a report is withdrawn.
DiagnosticReport.issued
Definition	The date and/or time that this version of the report was released from the source diagnostic service.
Control	1..1
Type	dateTime
Requirements	Clinicians need to be able to check the date that the report was released.
Aliases	Date Created; Date published; Date Issued
Summary	true
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.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	Resource(Patient \| Group \| Device \| Location)
Requirements	SHALL know the subject context.
Aliases	Patient
Summary	true
DiagnosticReport.performer
Definition	The diagnostic service that is responsible for issuing the report.
Control	1..1
Type	Resource(Practitioner \| Organization)
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.
Aliases	Laboratory; Service; Practitioner; Department; Company
Summary	true
Comments	This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.
DiagnosticReport.identifier
Definition	The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider.
Control	0..1
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.
Aliases	ReportID
Summary	true
DiagnosticReport.requestDetail
Definition	Details concerning a test requested.
Control	0..*
Type	Resource(DiagnosticOrder)
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.serviceCategory
Definition	The section of the diagnostic service that performs the examination e.g. biochemistry, hematology, MRI.
Control	0..1
Binding	DiagnosticServiceSection: HL7 v2 table 0074 (See http://hl7.org/fhir/vs/diagnostic-service-sections)
Type	CodeableConcept
Requirements	Help clinicians filter/find the reports they are looking for.
Aliases	Department; Sub-department; service; discipline
Summary	true
DiagnosticReport.diagnostic[x]
Definition	The time or time-period the observed values are related to. This is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
Control	1..1
Type	dateTime\|Period
Requirements	Need to know where in the patient history to file/present this report.
Aliases	Observation time; Effective Time
Summary	true
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.specimen
Definition	Details about the specimens on which this Disagnostic report is based.
Control	0..*
Type	Resource(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	0..*
Type	Resource(Observation)
Requirements	Need to be able to individual results, or report groups of results, where the result grouping is arbitrary, but meaningful. This structure is recursive - observations can contain observations.
Aliases	Data; Atomic Value; Result; Atomic result; Data; Test; Analyte; Battery; Organiser
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	Resource(ImagingStudy)
Comments	ImagingStudy and image are somewhat overlapping - typically, an image in the image list will also be found in the imaging study resource. However the imaging study and image lists cater 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..*
Requirements	Many diagnostic services include images in the report as part of their service.
Aliases	DICOM; Slides; Scans
Summary	true
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	Resource(Media)
Summary	true
DiagnosticReport.conclusion
Definition	Concise and clinically contextualized narrative interpretation of the diagnostic report.
Control	0..1
Type	string
Requirements	Need to be able to provide a conclusion that is not lost amongst the basic result data.
Aliases	Report
Comments	Typically, a report is either [all data, no narrative (e.g. Core lab)] or [a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density)], or [all narrative (e.g. typical imaging report, histopathology)]. In all of these cases, the narrative goes in "text".
DiagnosticReport.codedDiagnosis
Definition	Codes for the conclusion.
Control	0..*
Binding	AdjunctDiagnosis: SNOMED CT Clinical Findings (See http://hl7.org/fhir/vs/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.