This page is part of the Australian Base IG (v2.2.0: AU Base 2 on R4) based on FHIR R4. For a full list of available versions, see the Directory of published versions
DRAFT
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AU Pathology Result [FMM Level 0]
This profile defines an observation structure to represent a pathology test result issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics.
The observation may represent the result of a simple test such as haemoglobin or it may group the set of results produced by a multi-test study or panel such as a full blood count, or urine specimen study. In the latter cases, the observation carries the code of the study / panel and the overall comments in the note element, or a global interpretation by the producer of the study in the interpretation element. The observation references the individual test results that make up the study / panel as ‘has-member’ child observations.
No extensions are used in this profile.
This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.
When sending observations that group the set of results by a multi-test study or panel:
If the pathology laboratory is a discipline specific laboratory then one of the appropriate discipline specific value sets may be more suitable for use than the entire reporting set available in the profile:
Measurement of Hepatitis B surface antibody
The official URL for this profile is:
http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult
This profile defines an observation structure to represent a pathology test result issued by a diagnostic service provider in an Australian context. The observation may represent the result of a simple test such as haemoglobin or it may group the set of results produced by a multi-test study or panel such as a full blood count, or urine specimen study.
This profile builds on Observation.
This profile was published on Tue Jul 06 00:00:00 AEST 2021 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 |
---|---|---|---|---|
Observation | I | 0..* | Observation | A pathology test result in an Australian healthcare context inv-obs-0: One category shall be 'laboratory' 'http://terminology.hl7.org/CodeSystem/observation-category' inv-obs-1: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason |
category | 1..* | CodeableConcept | Pathology diagnostic service section Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (preferred) | |
code | 1..1 | CodeableConcept | Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
effective[x] | 1..1 | Time of specimen collection | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
specimen | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation | |
hasMember | 0..* | Reference(AU Diagnostic Result | AU Pathology Result) | Individual tests in a group or panel | |
component | 0..* | BackboneElement | Individual tests in a group or panel | |
code | 1..1 | CodeableConcept | Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | A pathology test result in an Australian healthcare context inv-obs-0: One category shall be 'laboratory' 'http://terminology.hl7.org/CodeSystem/observation-category' inv-obs-1: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business Identifier for observation |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | 1..* | CodeableConcept | Pathology diagnostic service section Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (preferred) | |
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record |
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
effective[x] | Σ | 1..1 | Time of specimen collection | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
value[x] | ΣI | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
low | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 0..1 | SimpleQuantity | High Range, if relevant |
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |
age | 0..1 | Range | Applicable age range, if relevant | |
text | 0..1 | string | Text based reference range in an observation | |
hasMember | Σ | 0..* | Reference(AU Diagnostic Result | AU Pathology Result) | Individual tests in a group or panel |
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from |
component | Σ | 0..* | BackboneElement | Individual tests in a group or panel |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 1..1 | CodeableConcept | Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) |
value[x] | Σ | 0..1 | Actual component result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |
Documentation for this format |
Differential View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | A pathology test result in an Australian healthcare context inv-obs-0: One category shall be 'laboratory' 'http://terminology.hl7.org/CodeSystem/observation-category' inv-obs-1: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason |
category | 1..* | CodeableConcept | Pathology diagnostic service section Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (preferred) | |
code | 1..1 | CodeableConcept | Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
effective[x] | 1..1 | Time of specimen collection | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
specimen | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation | |
hasMember | 0..* | Reference(AU Diagnostic Result | AU Pathology Result) | Individual tests in a group or panel | |
component | 0..* | BackboneElement | Individual tests in a group or panel | |
code | 1..1 | CodeableConcept | Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | A pathology test result in an Australian healthcare context inv-obs-0: One category shall be 'laboratory' 'http://terminology.hl7.org/CodeSystem/observation-category' inv-obs-1: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business Identifier for observation |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | 1..* | CodeableConcept | Pathology diagnostic service section Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (preferred) | |
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record |
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
effective[x] | Σ | 1..1 | Time of specimen collection | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
value[x] | ΣI | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
low | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 0..1 | SimpleQuantity | High Range, if relevant |
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |
age | 0..1 | Range | Applicable age range, if relevant | |
text | 0..1 | string | Text based reference range in an observation | |
hasMember | Σ | 0..* | Reference(AU Diagnostic Result | AU Pathology Result) | Individual tests in a group or panel |
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from |
component | Σ | 0..* | BackboneElement | Individual tests in a group or panel |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 1..1 | CodeableConcept | Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred) |
value[x] | Σ | 0..1 | Actual component result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |
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-pathologyresult
none defined