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
Official URL: http://hl7.org.au/fhir/StructureDefinition/au-imagingreport | Version: 4.1.0-ballot | |||
Draft as of 2022-11-10 | Maturity Level: 1 | Computable Name: AUBaseDiagnosticImagingReport | ||
Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved. |
This profile defines a diagnostic report structure to represent a diagnostic imaging report issued by a diagnostic service provider in an Australian context.
When constructing the report:
For a report of a multi-modality procedure:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Path | Conformance | ValueSet |
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
DiagnosticReport.conclusionCode | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A diagnostic imaging 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) | Diagnostic imaging order | |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
category | Σ | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region of interest Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
coding:anatomicRegionOfInterest | Σ | 0..* | Coding | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred) |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-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 imaging examination | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
result | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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 |
Path | Conformance | ValueSet |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
DiagnosticReport.conclusionCode | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A diagnostic imaging 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.
| |||||
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 | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |||||
basedOn | 0..* | Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan) | Diagnostic imaging order | |||||
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region of interest Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:anatomicRegionOfInterest | Σ | 0..* | Coding | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (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 imaging examination | |||||
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(Specimen) | Specimens this report is based on | |||||
result | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) | |||||
presentedForm | 0..* | Attachment | Entire report as issued | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 | ||||
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 | ||||
DiagnosticReport.conclusionCode | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements (1 nested mandatory element)
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from DiagnosticReport
Path | Conformance | ValueSet |
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-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 diagnostic imaging 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) | Diagnostic imaging order | |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
category | Σ | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region of interest Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
coding:anatomicRegionOfInterest | Σ | 0..* | Coding | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred) |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-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 imaging examination | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
result | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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 |
Path | Conformance | ValueSet |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
DiagnosticReport.conclusionCode | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A diagnostic imaging 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.
| |||||
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 | 0..* | Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber | Business identifier for report | |||||
basedOn | 0..* | Reference(ServiceRequest | AU Base Diagnostic Request | CarePlan) | Diagnostic imaging order | |||||
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region of interest Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:anatomicRegionOfInterest | Σ | 0..* | Coding | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (preferred) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (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 imaging examination | |||||
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(Specimen) | Specimens this report is based on | |||||
result | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging 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: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred) | |||||
presentedForm | 0..* | Attachment | Entire report as issued | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category.coding:anatomicRegionOfInterest | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 | ||||
DiagnosticReport.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 | ||||
DiagnosticReport.conclusionCode | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements (1 nested mandatory element)
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
none defined