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4.16 Resource DiagnosticReport - Content

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.

4.16.3 Resource Content

This resource is referenced by [Procedure]

<DiagnosticReport xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <name><!-- 1..1 CodeableConcept Name/Code for this diagnostic report --></name>
 <status value="[code]"/><!-- 1..1 registered | partial | final | corrected + § -->
 <issued value="[dateTime]"/><!-- 1..1 Date this version was released § -->
 <subject><!-- 1..1 Resource(Patient|Group|Device|Location) 
     The subject of the report, usually, but not always, the patient § --></subject>
 <performer><!-- 1..1 Resource(Practitioner|Organization) Responsible Diagnostic Service § --></performer>
 <identifier><!-- 0..1 Identifier Id for external references to this report § --></identifier>
 <requestDetail><!-- 0..* Resource(DiagnosticOrder) What was requested --></requestDetail>
 <serviceCategory><!-- 0..1 CodeableConcept Biochemistry, Hematology etc. § --></serviceCategory>
 <diagnostic[x]><!-- 1..1 dateTime|Period 
     Physiologically Relevant time/time-period for report § --></diagnostic[x]>
 <specimen><!-- 0..* Resource(Specimen) Specimens this report is based on --></specimen>
 <result><!-- 0..* Resource(Observation) Observations - simple, or complex nested groups --></result>
 <imagingStudy><!-- 0..* Resource(ImagingStudy) 
     Reference to full details of imaging associated with the diagnostic report --></imagingStudy>
 <image>  <!-- 0..* Key images associated with this report § -->
  <comment value="[string]"/><!-- 0..1 Comment about the image (e.g. explanation) -->
  <link><!-- 1..1 Resource(Media) Reference to the image source § --></link>
 </image>
 <conclusion value="[string]"/><!-- 0..1 Clinical Interpretation of test results -->
 <codedDiagnosis><!-- 0..* CodeableConcept Codes for the conclusion --></codedDiagnosis>
 <presentedForm><!-- 0..* Attachment Entire Report as issued --></presentedForm>
</DiagnosticReport>

Alternate definitions: Schema/Schematron, Resource Profile

4.16.3.1 Terminology Bindings

4.16.4 Notes:

• If the diagnostic procedure was performed on the patient directly, diagnostic[x] is a dateTime, the time it was performed. If specimens were taken, the diagnostically relevant time can be derived from the specimen collection times, but since detailed specimen information is not always available, and nor is the diagnostically relevant time always exactly the specimen collection time (e.g. complex timed tests), the reports SHALL always include a diagnostic[x] element. Note that v2 messages often carry a diagnostically relevant time without carrying any specimen information.
• A report always contains the name of the report itself. The report can also contain a set of observations, which can themselves be simple observations (e.g. atomic results) or can themselves be groups/panels of other observations. The Observation.name is a code that indicates the nature of the observation or panel (e.g. individual measure, organism isolate/sensitivity or antibody functional testing). When relevant, the observation can specify a particular specimen from which the result comes.
• There is rarely a need for more than two levels of nesting in the Observation tree. One known use is for organism sensitivities - see this example.
• Applications consuming diagnostic reports must take careful note of updated reports, and ensure that retracted reports are appropriately handled.
• For applications providing diagnostic reports, a report should not be final until all the individual data items reported with it are final or amended. If a report is retracted, all the results should be retracted by replacing every result value with the Concept "withdrawn" in the internal terminology "Special values" (url = "http://hl7.org/fhir/special-values"), and setting the conclusion (if provided) and the text narrative to some text like "This report has been withdrawn" in the appropriate language. A reason for retraction may be provided in the narrative.

4.16.4.1 Report Content

This resource provides for 3 different ways of presenting the Diagnostic Report:

• As atomic data items: a hierarchical set of nested references to Observation resources, one or more images, and possibly with a conclusion and/or one or more coded diagnoses
• As narrative: an XHTML presentation in the standard resource narrative
• As a "presented form": A rich text representation of the report - typically a PDF

Note that the conclusion and the coded diagnoses are part of the atomic data, and SHOULD be duplicated in the narrative and in the presented form if the latter is present. The narrative and the presented form serve the same function: a representation of the report for a human. The presented form is included since diagnostic service reports often contain presentation features that are not easy to reproduce in the HTML narrative. Whether or not the presented form is included, the narrative must be a clinically safe view of the diagnostic report; at a minimum, this could be fulfilled by a note indicating that the narrative is not proper representation of the report, and that the presented form must be used, or a generated view from the atomic data. However consumers of the report will best be served if the narrative contains clinically relevant data from the form. Commonly, the following patterns are used:

• Simple Laboratory Reports: A single set of atomic observations, and a tabular presentation in narrative. Typically this is encountered in high volume areas such as Biochemistry and Hematology
• Histopathology Report: A document report in a presented form and the narrative. Possibly a few key images, and some coded diagnoses for registries. If the service is creating a structured report, some atomic data may be included
• imaging Report; A document report in a presented form and the narrative, with an imaging study reference and possibly some key images. Some imaging reports such as a Bone Density Scan may include some atomic data

Note that the nature of reports from the various disciplines that provide diagnostic reports are changing quickly, as expert systems provide improved narrative reporting in high volume reports, structured reporting brings additional data to areas that have classically been narrative based, and the nature of the imaging and laboratory procedures are merging. As a consequence the patterns described above are only examples of how a diagnostic report can be used.

4.16.5 Search Parameters

Search parameters for this resource. The standard parameters also apply. See Searching for more information about searching in REST, messaging, and services.