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 Result

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

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

This profile defines an observation structure to represent a diagnostic investigation result issued by a diagnostic service provider in an Australian context.

The observation may represent the result of a simple investigation or it may group the set of results of a multi-modality procedure or multi-test study / panel.

This profile may be used to represent a specialist or other diagnostic (not imaging or pathology) observation including results of audiology studies, sleep studies or speech pathology.

Boundaries and relationships

Use the AU Base Pathology Result profile to represent the result of a pathology test.

Use the AU Base Diagnostic Imaging Result profile to represent the result of a radiology examination or an imaging intensive diagnostic investigation.

Usage Notes

The bodySite extension may be used when a coded concept does not provide the necessary detail needed for the use case.

Usage:

  • Refer to this Resource Profile:

Formal Views of Profile Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
... effective[x] 1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... hasMember 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
: value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptDiagnostic procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... effective[x] Σ1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... hasMember Σ0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
: value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... 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
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptDiagnostic procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... 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
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... 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
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
... effective[x] 1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... hasMember 0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
: value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptDiagnostic procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... effective[x] Σ1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... hasMember Σ0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
: value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA diagnostic result observation in an Australian healthcare context
inv-obs-0: A diagnostic result shall at least have value or data absent reason or a child observation with a value or data absent reason
... 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
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 1..*CodeableConceptDiagnostic service section
Binding: DiagnosticServiceSectionCodes (preferred)
... code Σ1..1CodeableConceptDiagnostic procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (example)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... 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
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result | AU Base Pathology Result)Individual examinations in a group or study series
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... 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
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredDiagnosticServiceSectionCodes
Observation.codeexamplehttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

 

Other representations of profile: CSV, Excel, Schematron

Notes:

none defined