AU Base Pathology Report - AU Base Implementation Guide v5.0.0

AU Base Implementation Guide
5.0.0 - Working Standard Australia flag

This page is part of the Australian Base IG (v5.0.0: R4) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Pathology Report

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyreport		Version: 5.0.0
Standards status: Trial-use	Maturity Level: 1	Computable Name: AUBasePathologyReport
Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines a diagnostic report structure to represent a pathology report issued by a diagnostic service provider in an Australian context. 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.

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

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:

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.

This structure is derived from AUBaseDiagnosticReport

Name	Card.	Type	Description & Constraints
DiagnosticReport	0..*	AUBaseDiagnosticReport	A pathology report in an Australian healthcare context
identifier	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn	0..*	Reference(ServiceRequest \| CarePlan)	Pathology order
category	1..*	CodeableConcept	Service category Binding: Pathology Diagnostic Service Category (extensible)
code	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (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: Clinical Finding (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.category	extensible	PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code	preferred	RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode	preferred	ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	AUBaseDiagnosticReport	A pathology report in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	Σ	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report ele-1: All FHIR elements must have a @value or children
basedOn		0..*	Reference(ServiceRequest \| CarePlan)	Pathology order ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
category	Σ	1..*	CodeableConcept	Service category Binding: Pathology Diagnostic Service Category (extensible) ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient)	The subject of the report - usually, but not always, the patient ele-1: All FHIR elements must have a @value or children
effective[x]	Σ	1..1		Time of specimen collection ele-1: All FHIR elements must have a @value or children
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..*	Reference(AU Base Specimen)	Specimens this report is based on ele-1: All FHIR elements must have a @value or children
result		0..*	Reference(AU Base Diagnostic Result \| AU Base Pathology Result)	Observations ele-1: All FHIR elements must have a @value or children
conclusionCode		0..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status\|4.0.1` from the FHIR Standard
DiagnosticReport.category	extensible	PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code	preferred	RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode	preferred	ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

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()

Description & Constraints

DiagnosticReport

0..*

AUBaseDiagnosticReport

A pathology report in an Australian healthcare context

id

Σ

0..1

id

Logical id of this artifact

Terminology Bindings

Path Conformance ValueSet URI

DiagnosticReport.language

preferred

CommonLanguages

http://hl7.org/fhir/ValueSet/languages

from the FHIR Standard

Additional Bindings

Purpose

AllLanguages

Max Binding

DiagnosticReport.status

required

DiagnosticReportStatus

http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1

from the FHIR Standard

DiagnosticReport.category

extensible

PathologyDiagnosticServiceCategory

https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1

from https://tx.ontoserver.csiro.au/fhir

DiagnosticReport.code

preferred

RCPASPIAPathologyReporting

https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

from https://tx.ontoserver.csiro.au/fhir

DiagnosticReport.conclusionCode

preferred

ClinicalFinding

https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

from https://tx.ontoserver.csiro.au/fhir

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()

This structure is derived from AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Maturity: 1

Differential View

This structure is derived from AUBaseDiagnosticReport

Name	Card.	Type	Description & Constraints
DiagnosticReport	0..*	AUBaseDiagnosticReport	A pathology report in an Australian healthcare context
identifier	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report
basedOn	0..*	Reference(ServiceRequest \| CarePlan)	Pathology order
category	1..*	CodeableConcept	Service category Binding: Pathology Diagnostic Service Category (extensible)
code	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (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: Clinical Finding (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.category	extensible	PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code	preferred	RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode	preferred	ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	AUBaseDiagnosticReport	A pathology report in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	Σ	0..*	Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumber	Business identifier for report ele-1: All FHIR elements must have a @value or children
basedOn		0..*	Reference(ServiceRequest \| CarePlan)	Pathology order ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
category	Σ	1..*	CodeableConcept	Service category Binding: Pathology Diagnostic Service Category (extensible) ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient)	The subject of the report - usually, but not always, the patient ele-1: All FHIR elements must have a @value or children
effective[x]	Σ	1..1		Time of specimen collection ele-1: All FHIR elements must have a @value or children
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..*	Reference(AU Base Specimen)	Specimens this report is based on ele-1: All FHIR elements must have a @value or children
result		0..*	Reference(AU Base Diagnostic Result \| AU Base Pathology Result)	Observations ele-1: All FHIR elements must have a @value or children
conclusionCode		0..*	CodeableConcept	Codes for the clinical conclusion of test results Binding: Clinical Finding (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status\|4.0.1` from the FHIR Standard
DiagnosticReport.category	extensible	PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.code	preferred	RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` from https://tx.ontoserver.csiro.au/fhir
DiagnosticReport.conclusionCode	preferred	ClinicalFinding `https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1` from https://tx.ontoserver.csiro.au/fhir

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

Description & Constraints

DiagnosticReport

0..*

AUBaseDiagnosticReport

A pathology report in an Australian healthcare context

id

Σ

0..1

id

Logical id of this artifact

Terminology Bindings

Path Conformance ValueSet URI

DiagnosticReport.language

preferred

CommonLanguages

http://hl7.org/fhir/ValueSet/languages

from the FHIR Standard

Additional Bindings

Purpose

AllLanguages

Max Binding

DiagnosticReport.status

required

DiagnosticReportStatus

http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1

from the FHIR Standard

DiagnosticReport.category

extensible

PathologyDiagnosticServiceCategory

https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1

from https://tx.ontoserver.csiro.au/fhir

DiagnosticReport.code

preferred

RCPASPIAPathologyReporting

https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

from https://tx.ontoserver.csiro.au/fhir

DiagnosticReport.conclusionCode

preferred

ClinicalFinding

https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

from https://tx.ontoserver.csiro.au/fhir

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()

This structure is derived from AUBaseDiagnosticReport

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Maturity: 1

Other representations of profile: CSV, Excel, Schematron

IG © 2017+ HL7 Australia. Package hl7.fhir.au.base#5.0.0 based on FHIR 4.0.1. Generated 2025-01-15
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