AU Base Implementation Guide
4.1.1-preview - Preview Australia flag

This page is part of the AU Base Implementation Guide 4.1.1-preview 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: 4.1.1-preview
Standards status: Trial-use 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.

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 diagnostic 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.
  • See the AU Base Pathology Report profile for guidance on representing a pathology report issued by the diagnostic service provider.
  • See the AU Base Diagnostic Imaging Report profile for guidance on representing an 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 (preferred)
... 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.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
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 (preferred)
... 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.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

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 (preferred)
... 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.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

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 (preferred)
... 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.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron