AU Base Pathology Report - AU Base Implementation Guide v4.1.2-preview

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

Name	Card.	Type	Description & Constraints
DiagnosticReport	0..*	DiagnosticReport	A pathology report in an Australian healthcare context
identifier	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn	0..*	Reference(ServiceRequest \| AU Base Diagnostic Request \| CarePlan)	Pathology order
category	1..*	CodeableConcept	Service category Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
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)	The subject of the report - usually, but not always, the patient
effective[x]	1..1	dateTime, Period	Time 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..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DiagnosticReport.category	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCode	preferred	https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A pathology report in an Australian healthcare context
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn		0..*	Reference(ServiceRequest \| AU Base Diagnostic Request \| CarePlan)	Pathology order
status	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	Σ	1..*	CodeableConcept	Service category Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
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)	The subject of the report - usually, but not always, the patient
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
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..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.status	required	DiagnosticReportStatus
DiagnosticReport.category	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCode	preferred	https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If 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-4	error	DiagnosticReport	If 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-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	ALL elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	ALL extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Description & Constraints

DiagnosticReport

0..*

DiagnosticReport

A pathology report in an Australian healthcare context

id

Σ

0..1

id

Logical id of this artifact

Terminology Bindings

Path

Conformance

ValueSet

DiagnosticReport.language

preferred

CommonLanguages

Additional Bindings

Purpose

AllLanguages

Max Binding

DiagnosticReport.status

required

DiagnosticReportStatus

DiagnosticReport.category

extensible

https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1

DiagnosticReport.code

preferred

https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

DiagnosticReport.conclusionCode

preferred

https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If 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-4	error	DiagnosticReport	If 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-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	ALL elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	ALL extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Maturity: 1

Differential View

This structure is derived from DiagnosticReport

Name	Card.	Type	Description & Constraints
DiagnosticReport	0..*	DiagnosticReport	A pathology report in an Australian healthcare context
identifier	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn	0..*	Reference(ServiceRequest \| AU Base Diagnostic Request \| CarePlan)	Pathology order
category	1..*	CodeableConcept	Service category Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
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)	The subject of the report - usually, but not always, the patient
effective[x]	1..1	dateTime, Period	Time 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..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DiagnosticReport.category	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCode	preferred	https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A pathology report in an Australian healthcare context
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn		0..*	Reference(ServiceRequest \| AU Base Diagnostic Request \| CarePlan)	Pathology order
status	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	Σ	1..*	CodeableConcept	Service category Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
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)	The subject of the report - usually, but not always, the patient
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
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..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.status	required	DiagnosticReportStatus
DiagnosticReport.category	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
DiagnosticReport.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
DiagnosticReport.conclusionCode	preferred	https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If 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-4	error	DiagnosticReport	If 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-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	ALL elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	ALL extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Description & Constraints

DiagnosticReport

0..*

DiagnosticReport

A pathology report in an Australian healthcare context

id

Σ

0..1

id

Logical id of this artifact

Terminology Bindings

Path

Conformance

ValueSet

DiagnosticReport.language

preferred

CommonLanguages

Additional Bindings

Purpose

AllLanguages

Max Binding

DiagnosticReport.status

required

DiagnosticReportStatus

DiagnosticReport.category

extensible

https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1

DiagnosticReport.code

preferred

https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

DiagnosticReport.conclusionCode

preferred

https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	If 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-4	error	DiagnosticReport	If 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-5	error	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	ALL elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	ALL extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Maturity: 1

Other representations of profile: CSV, Excel, Schematron

IG © 2017+ HL7 Australia. Package hl7.fhir.au.base#4.1.2-preview based on FHIR 4.0.1. Generated 2023-11-15
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