AU Base Implementation Guide
4.1.0 - Trial Use Australia flag

This page is part of the AU Base Implementation Guide 4.1.0. It is based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Diagnostic Imaging Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-imagingreport Version: 4.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBaseDiagnosticImagingReport

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines a diagnostic report structure to represent a diagnostic imaging report issued by a diagnostic service provider in an Australian context.

Usage Notes

Profile specific implementation guidance:

  • Results that are free text or report form are represented in DiagnosticReport.presentedForm.
  • Results that are structured in FHIR resources are referenced in DiagnosticResult.result. Each referenced Observation resource represents an individual imaging examination and result value or component result values, or a nested grouping of Observations such as a multi-modality procedure which references other Observations in Observation.hasMember.
  • When constructing a report for a nested grouping of Observations:
    • the individual imaging examinations are referenced by that grouping Observation in Observation.hasMember and not directly referenced in DiagnosticReport.result
    • DiagnosticReport.code and the grouping Observation Observation.code should be the same concept if the report contains only the results of that group.
  • See each Identifier profile page for guidance related to that identifier type.
  • The radiology laboratory is sent as a reference to an Organization in DiagnosticReport.performer.
  • Each radiologist is sent as a references to a PractitionerRole resource in DiagnosticReport.performer.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Diagnostic imaging order
... category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest 0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... subject 1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] 1..1dateTime, PeriodTime of imaging examination
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest Σ0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] Σ1..1Time of imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Diagnostic imaging order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest Σ0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... 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)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Time of imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... 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
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from DiagnosticReport

Summary

Mandatory: 3 elements (1 nested mandatory element)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category.coding is sliced based on the value of value:system

Maturity: 1

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Diagnostic imaging order
... category 1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest 0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... subject 1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] 1..1dateTime, PeriodTime of imaging examination
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest Σ0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
... code Σ1..1CodeableConceptDiagnostic imaging examination or study
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] Σ1..1Time of imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic imaging report in an Australian healthcare context
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Diagnostic imaging order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptRelevant diagnostic imaging category: service, modality and anatomic region of interest
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:anatomicRegionOfInterest Σ0..*CodingAnatomic Region Of Interest
Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred)
...... 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)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Time of imaging examination
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... 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
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category.coding:anatomicRegionOfInterestpreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from DiagnosticReport

Summary

Mandatory: 3 elements (1 nested mandatory element)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category.coding is sliced based on the value of value:system

Maturity: 1

 

Other representations of profile: CSV, Excel, Schematron