Australian Base Implementation Guide

This page is part of AU Base v4.0.0 based on FHIR R4. For a full list of available versions, see the Directory of published versions

1.0 StructureDefinition-au-imagingresult

AU Diagnostic Imaging Result [FMM 1]

This profile defines an observation structure to represent an imaging examination result issued by a diagnostic service provider in an Australian context. The observation may represent the result of a simple examination or study series.

The observation may represent the result of a simple examination or it may group the set of results produced by a study series. 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 observations that make up the study as ‘has-member’ child observations.

Extensions

Extensions used in this profile:

  • Observation: bodySite (core extension)

Usage Notes

The bodySite extension may be used when a coded concept does not provide the necessary detail needed for the use case.

When sending observations that group the set of results of a multi-modality procedure:

  • a multi-modality procedure observation is sent with individual component examinations in Observation.hasMember
  • an individual component examination observation is referenced by that multi-modality procedure observation (Observation.hasMember) rather than directly at the diagnostic report level (DiagnosticReport.result)

Examples

There are no examples available for this profile.

1.0.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org.au/fhir/StructureDefinition/au-imagingresult

This profile defines an observation structure to represent a imaging examination result issued by a diagnostic service provider in an Australian context. The observation may represent the result of a simple examination or study series.

This profile builds on Observation.

This profile was published on 2022-05-30 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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationA imaging examination result in an Australian healthcare context
inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... Slices for category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:diagImg 1..1CodeableConceptObservation generated by imaging
..... coding 1..*CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
.... category:anatomicRegionOfInterest 0..*CodeableConceptAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible)
..... coding
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... code 1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
... effective[x] 1..1Time of diagnostic imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... bodySite 0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... hasMember 0..*Reference(AU Diagnostic Result | AU Diagnostic Imaging Result)Individual examinations in a group or study series
... component 0..*BackboneElementIndividual examinations in a group or study series
.... code 1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationA imaging examination result in an Australian healthcare context
inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:diagImg 1..1CodeableConceptObservation generated by imaging
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... category:anatomicRegionOfInterest 0..*CodeableConceptAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Time of diagnostic imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣI0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(AU Diagnostic Result | AU Diagnostic Imaging Result)Individual examinations in a group or study series
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIndividual examinations in a group or study series
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationA imaging examination result in an Australian healthcare context
inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... Slices for category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:diagImg 1..1CodeableConceptObservation generated by imaging
..... coding 1..*CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
.... category:anatomicRegionOfInterest 0..*CodeableConceptAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible)
..... coding
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... code 1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
... effective[x] 1..1Time of diagnostic imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... bodySite 0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... hasMember 0..*Reference(AU Diagnostic Result | AU Diagnostic Imaging Result)Individual examinations in a group or study series
... component 0..*BackboneElementIndividual examinations in a group or study series
.... code 1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationA imaging examination result in an Australian healthcare context
inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:diagImg 1..1CodeableConceptObservation generated by imaging
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... category:anatomicRegionOfInterest 0..*CodeableConceptAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Time of diagnostic imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣI0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(AU Diagnostic Result | AU Diagnostic Imaging Result)Individual examinations in a group or study series
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIndividual examinations in a group or study series
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

1.0.2 Quick Start

Below is an overview of the required search and read operations.

Summary of Search Criteria for StructureDefinition-au-imagingresult

none defined

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