Australian Base Implementation Guide (AU Base 2)
This page is part of the Australian Base IG (v2.1.0: AU Base 2 on R4) based on FHIR R4. For a full list of available versions, see the Directory of published versions 
DRAFT
ONLY
AU Base Diagnostic Report [FMM Level 0]
This profile is intended to support all diagnostic reports including, pathology, diagnostic imaging and other diagnostic reports such as electrocardiograms, electroencephalograms, pulmonary function tests, colonoscopies, etc.
There are three preferred value sets when coding DiagnosticReport.code:
These definitions represent common data held in the DiagnosticReport.identifier element:
The official URL for this profile is:
http://hl7.org.au/fhir/StructureDefinition/au-diagnosticreport
This profile defines a diagnostic report structure that includes core localisation concepts for use in an Australian context.
This profile builds on DiagnosticReport.
This profile was published on Thu Feb 13 00:00:00 AEDT 2020 as a draft by Health Level Seven Australia (Orders and Observations WG).
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |
  identifier | 0..* | (Slice Definition) | Business identifier for report Slice: Unordered, Open by pattern:type | |
   identifier:fillerIdentifier | 0..* | Identifier | Filler report identifier | |
   type | 1..1 | CodeableConcept | Description of identifier Binding: V2 Identifier Type - AU Extended (required) | |
  coding | 1..1 | Coding | Code defined by a terminology system | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |
| system | 1..1 | uri | Filler identifier system namespace | |
 value | 1..1 | string | Filler identifier | |
| category | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
 specimen | 0..* | Reference(AU Base Specimen) | Specimens this report is based on | |
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | I | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | (Slice Definition) | Business identifier for report Slice: Unordered, Open by pattern:type |
| identifier:fillerIdentifier | ΣI | 0..* | Identifier | Filler report identifier |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 1..1 | CodeableConcept | Description of identifier Binding: V2 Identifier Type - AU Extended (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| system | ΣI | 1..1 | uri | Filler identifier system namespace Example General: http://www.acme.com/identifiers/patient |
| value | ΣI | 1..1 | string | Filler identifier Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| category | ΣI | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) |
| code | ΣI | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred) |
| subject | ΣI | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
 effective[x] | ΣI | 0..1 | Clinically relevant time/time-period for report | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| specimen | I | 0..* | Reference(AU Base Specimen) | Specimens this report is based on |
| result | I | 0..* | Reference(Observation) | Observations |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | I | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context | |
| identifier | 0..* | (Slice Definition) | Business identifier for report Slice: Unordered, Open by pattern:type | |
| identifier:fillerIdentifier | 0..* | Identifier | Filler report identifier | |
| type | 1..1 | CodeableConcept | Description of identifier Binding: V2 Identifier Type - AU Extended (required) | |
| coding | 1..1 | Coding | Code defined by a terminology system | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |
| system | 1..1 | uri | Filler identifier system namespace | |
| value | 1..1 | string | Filler identifier | |
| category | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) | |
| specimen | 0..* | Reference(AU Base Specimen) | Specimens this report is based on | |
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | I | 0..* | DiagnosticReport | A diagnostic report in an Australian healthcare context |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | (Slice Definition) | Business identifier for report Slice: Unordered, Open by pattern:type |
| identifier:fillerIdentifier | ΣI | 0..* | Identifier | Filler report identifier |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 1..1 | CodeableConcept | Description of identifier Binding: V2 Identifier Type - AU Extended (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| system | ΣI | 1..1 | uri | Filler identifier system namespace Example General: http://www.acme.com/identifiers/patient |
| value | ΣI | 1..1 | string | Filler identifier Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| category | ΣI | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (preferred) |
| code | ΣI | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred) |
| subject | ΣI | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
| effective[x] | ΣI | 0..1 | Clinically relevant time/time-period for report | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| specimen | I | 0..* | Reference(AU Base Specimen) | Specimens this report is based on |
| result | I | 0..* | Reference(Observation) | Observations |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | I | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
Below is an overview of the required search and read operations.
Summary of Search Criteria for StructureDefinition-au-diagnosticreport
none defined
© AU Base 2 on FHIR R4 (IG Publisher v4.0.1-a53ec6ee1b) generated on Thu, Jul 30, 2020 13:57+1000. |
