AU Base Implementation Guide
4.1.2-preview - Preview Australia flag

This page is part of the Australian Base IG (v4.1.2-preview: AU Base) based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Pathology Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyreport Version: 4.1.2-preview
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBasePathologyReport

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

This profile defines a diagnostic report structure to represent a pathology report 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.

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.

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 pathology test and result value or component result values, or a study / panel which references other Observations in Observation.hasMember.
  • When constructing a report for a study / panel:
    • the individual component examinations are referenced by that grouping Observation in Observation.hasMember and not directly referenced in DiagnosticReport.result
    • DiagnosticReport.code and the study / panel Observation Observation.code should be the same concept if the report contains only the results of that study / panel
  • See each Identifier profile page for guidance related to that identifier type.
  • effective[x] is the earliest specimen collection date time.
  • The pathology laboratory is sent as a reference to an Organization in DiagnosticReport.performer.
  • Each pathologist is sent as a reference to a PractitionerRole resource in DiagnosticReport.performer.
  • When sending a discipline specific laboratory result, one of discipline specific value sets may be more suitable for use than the entire reporting value set bound in this profile to DiagnosticReport.code:

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 pathology report in an Australian healthcare context
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Pathology order
... category 1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... subject 1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] 1..1dateTime, PeriodTime of specimen collection
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA pathology 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..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 pathology 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)Pathology order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 specimen collection
.... 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(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA pathology report in an Australian healthcare context
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan)Pathology order
... category 1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... subject 1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] 1..1dateTime, PeriodTime of specimen collection
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA pathology 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..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 pathology 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)Pathology order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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 specimen collection
.... 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(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Base Diagnostic Result | AU Base Pathology 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.categoryextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-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()

 

Other representations of profile: CSV, Excel, Schematron