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 pathology 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.
• effective[x] is the earliest specimen collection date time.
• The pathology laboratory is sent as a reference to an Organization in DiagnosticReport.performer.
• Each pathologist is sent as a reference to a PractitionerRole resource in DiagnosticReport.performer.
• When sending a discipline specific laboratory result, one of discipline specific value sets may be more suitable for use than the entire reporting value set bound in this profile to DiagnosticReport.code:
  • 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

Constraints

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

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

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

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

Constraints

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

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

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

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