AU Base Implementation Guide
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## Resource Profile: AU Base Pathology Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyreport | Version: 5.1.0-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`:
  - ValueSet : RCPA - SPIA Chemical Pathology Terminology Reference Set
  - ValueSet : RCPA - SPIA Haematology Terminology Reference Set
  - ValueSet : RCPA - SPIA Immunopathology Terminology Reference Set
  - ValueSet : RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set

Usage:

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

Changes since version 5.0.0:

- No changes

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier | Σ | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report ele-1: All FHIR elements must have a @value or children
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service Request | CarePlan) | Pathology order ele-1: All FHIR elements must have a @value or children
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
category | Σ | 1..* | CodeableConcept | Service category Binding: Pathology Diagnostic Service Category (extensible) ele-1: All FHIR elements must have a @value or children
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) ele-1: All FHIR elements must have a @value or children
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient ele-1: All FHIR elements must have a @value or children
effective[x] | Σ | 1..1 |  | Time of specimen collection ele-1: All FHIR elements must have a @value or children
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
specimen |  | 0..* | Reference(AU Base Specimen) | Specimens this report is based on ele-1: All FHIR elements must have a @value or children
result |  | 0..* | Reference(AU Base Diagnostic Result | AU Base Pathology Result) | Observations ele-1: All FHIR elements must have a @value or children
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` from the FHIR Standard
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

#### 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 AUBaseDiagnosticReport

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context
identifier |  | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service Request | CarePlan) | Pathology order
category |  | 1..* | CodeableConcept | Service category Binding: Pathology Diagnostic Service Category (extensible)
code |  | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (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: Clinical Finding (preferred)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context
id | Σ | 0..1 | id | 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): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service 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: Pathology Diagnostic Service Category (extensible)
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred)
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered
effective[x] | Σ | 1..1 |  | Time of specimen collection
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | 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 | Σ | 0..* | BackboneElement | Key images associated with this report
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
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion |  | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` from the FHIR Standard
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

#### 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 AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

- AU Base Service Request (http://hl7.org.au/fhir/StructureDefinition/au-servicerequest)
- AU Base Specimen (http://hl7.org.au/fhir/StructureDefinition/au-specimen)
- AU Base Diagnostic Result (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticresult)
- AU Base Pathology Result (http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult)

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier | Σ | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report ele-1: All FHIR elements must have a @value or children
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service Request | CarePlan) | Pathology order ele-1: All FHIR elements must have a @value or children
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
category | Σ | 1..* | CodeableConcept | Service category Binding: Pathology Diagnostic Service Category (extensible) ele-1: All FHIR elements must have a @value or children
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) ele-1: All FHIR elements must have a @value or children
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient ele-1: All FHIR elements must have a @value or children
effective[x] | Σ | 1..1 |  | Time of specimen collection ele-1: All FHIR elements must have a @value or children
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
specimen |  | 0..* | Reference(AU Base Specimen) | Specimens this report is based on ele-1: All FHIR elements must have a @value or children
result |  | 0..* | Reference(AU Base Diagnostic Result | AU Base Pathology Result) | Observations ele-1: All FHIR elements must have a @value or children
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` from the FHIR Standard
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

#### 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() |

Differential View

This structure is derived from AUBaseDiagnosticReport

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context
identifier |  | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service Request | CarePlan) | Pathology order
category |  | 1..* | CodeableConcept | Service category Binding: Pathology Diagnostic Service Category (extensible)
code |  | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (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: Clinical Finding (preferred)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | AUBaseDiagnosticReport | A pathology report in an Australian healthcare context
id | Σ | 0..1 | id | 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): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report
basedOn |  | 0..* | Reference(ServiceRequest | AU Base Service 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: Pathology Diagnostic Service Category (extensible)
code | Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred)
subject | Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered
effective[x] | Σ | 1..1 |  | Time of specimen collection
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | 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 | Σ | 0..* | BackboneElement | Key images associated with this report
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
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion |  | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` from the FHIR Standard
DiagnosticReport.category | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code | preferred | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode | preferred | ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

#### 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 AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

- AU Base Service Request (http://hl7.org.au/fhir/StructureDefinition/au-servicerequest)
- AU Base Specimen (http://hl7.org.au/fhir/StructureDefinition/au-specimen)
- AU Base Diagnostic Result (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticresult)
- AU Base Pathology Result (http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult)

Maturity: 1

Other representations of profile: CSV, Excel, Schematron