AU Base Implementation Guide
4.1.0-ballot - CI Build AU

This page is part of AU Base v4.1.0 based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Diagnostic Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-diagnosticreport Version: 4.1.0-ballot
Draft as of 2022-11-10 Maturity Level: 1 Computable Name: AUBaseDiagnosticReport

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

This profile defines a diagnostic report structure that localises core concepts, including identifiers and terminology, for use in an Australian context.

The purpose of this profile is to provide national level agreement on core localised concepts.

This profile does not force conformance to core localised concepts. It enables implementers and modellers to make their own rules, i.e. profiling, about how to support these concepts for specific implementation needs.

Boundaries and relationships

Use the AU Base Pathology Report profile to represent a pathology report issued by the diagnostic service provider.

Use the AU Base Diagnostic Imaging Report profile to represent a diagnostic imaging report issued by the diagnostic service provider.

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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic 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 Σ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.categorypreferredDiagnosticServiceSectionCodes
DiagnosticReport.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ0..1Reference(Patient | Group | Device | Location)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... 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(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.categorypreferredDiagnosticServiceSectionCodes
DiagnosticReport.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic 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 Σ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.categorypreferredDiagnosticServiceSectionCodes
DiagnosticReport.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA diagnostic 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | AU Base Diagnostic Request)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ0..1Reference(Patient | Group | Device | Location)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... 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(Observation | AU Base Diagnostic Result | AU Base Diagnostic Imaging 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.categorypreferredDiagnosticServiceSectionCodes
DiagnosticReport.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

 

Other representations of profile: CSV, Excel, Schematron

Notes:

none defined