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.

Boundaries and relationships

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

When constructing the report:

• a local identifier is sent with a HPI-O scoped identifier namespace if there isn't a local namespace available (see the FAQ) for more information
• code matches one Observation.code referenced in result
• effective[x] is the earliest specimen collection date time
• performer is sent as one Organization (pathology laboratory) and one or more PractitionerRoles (pathologist)

For a report of a multi-test study or panel:

• result is sent with the Observation representing the study / panel
• code is sent with the same code in that study / panel Observation
• the individual component tests are referenced by that Observation (Observation.hasMember) and not the DiagnosticReport

If the pathology laboratory is a discipline specific laboratory then one of the appropriate discipline specific value sets may be more suitable for use than the entire reporting set available in the profile:

• 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

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

This structure is derived from DiagnosticReport

Name	Flags	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

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	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		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
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: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

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

Differential View

This structure is derived from DiagnosticReport

Name	Flags	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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	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		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
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: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

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

This structure is derived from DiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

• AU Base Diagnostic Request (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticrequest)
• 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

none defined