AU Core Implementation Guide
0.1.0-draft - Draft Australia flag

This page is part of the AU Core Implementation Guide 0.1.0 Draft. It is based on AU Base 4.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core DiagnosticReport

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-diagnosticreport Version: 0.1.0-draft
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreDiagnosticReport

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

​This profile sets minimum expectations for a DiagnosticReport resource to record, search, and fetch diagnostic reports associated with a patient. It is based on the AU Base Diagnostic Report profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the DiagnosticReport when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for a specific diagnostic report such as an electrocardiogram (ECG) or full blood count (FBC).
  • Query for category of diagnostic report (e.g. all cardiology reports)
  • Record or update a diagnostic report for a patient

Profile specific implementation guidance

  • DiagnosticReport.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • Results that are free text or report form are represented using ‘DiagnosticReport.presentedForm`.
  • References to a Media resource are preferred to be contained but may be an external resource
  • The DiagnosticReport resource can represent the clinical conclusion as a text summary with DiagnosticReport.conclusion or a set of codes with DiagnosticReport.conclusionCode.
    • Although both are marked as must support, sending systems are not required to support both a text and a set of codes, but they SHALL support at least one of these elements
    • A receiving or persisting system SHALL support both elements
  • The DiagnosticReport resource can represent the result as a text summary with DiagnosticReport.conclusion or a set of codes with DiagnosticReport.conclusionCode.
    • Although both are marked as must support, sending systems are not required to support both a text and a set of codes, but they SHALL support at least one of these elements
    • A receiving or persisting system SHALL support both elements

Usage:

  • Refer to this Resource Profile:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from AUBaseDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... identifier S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn S0..*Reference(AU Core ServiceRequest)Diagnostic investigation order
... status S1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... code S1..1CodeableConceptDiagnostic examination name / study name / group name
... subject S1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... effective[x] SC1..1dateTime, PeriodClinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
... issued S1..1instantDiagnostic report date time
... performer S1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)Responsible Diagnostic Service
... result SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... media S0..*BackboneElementKey images associated with this report
.... link S1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... status ?!SΣ1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ1..1CodeableConceptDiagnostic examination name / study name / group name
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (preferred)
... subject SΣ1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... effective[x] SΣC1..1Clinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDiagnostic report date time
... performer SΣ1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)Responsible Diagnostic Service
... result SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... 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 S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn S0..*Reference(AU Core ServiceRequest)Diagnostic investigation order
... status ?!SΣ1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ1..1CodeableConceptDiagnostic examination name / study name / group name
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (preferred)
... subject SΣ1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣC1..1Clinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDiagnostic report date time
... performer SΣ1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)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 SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.result.typeextensibleResourceType
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Differential View

This structure is derived from AUBaseDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... identifier S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn S0..*Reference(AU Core ServiceRequest)Diagnostic investigation order
... status S1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... code S1..1CodeableConceptDiagnostic examination name / study name / group name
... subject S1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... effective[x] SC1..1dateTime, PeriodClinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
... issued S1..1instantDiagnostic report date time
... performer S1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)Responsible Diagnostic Service
... result SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... media S0..*BackboneElementKey images associated with this report
.... link S1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... status ?!SΣ1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ1..1CodeableConceptDiagnostic examination name / study name / group name
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (preferred)
... subject SΣ1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... effective[x] SΣC1..1Clinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDiagnostic report date time
... performer SΣ1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)Responsible Diagnostic Service
... result SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-01errorDiagnosticReportThe report shall at least have a result or a presentedForm
: result.exists() or presentedForm.exists()
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*AUBaseDiagnosticReportA diagnostic report in an Australian healthcare context
au-core-dir-01: The report shall at least have a result or a presentedForm
... 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 S1..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn S0..*Reference(AU Core ServiceRequest)Diagnostic investigation order
... status ?!SΣ1..1codepartial | preliminary | final +
Binding: https://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1 (required)
... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (extensible)
... code SΣ1..1CodeableConceptDiagnostic examination name / study name / group name
Binding: https://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1 (preferred)
... subject SΣ1..1Reference(AU Core Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣC1..1Clinically relevant time/time-period for report
au-core-dir-04: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDiagnostic report date time
... performer SΣ1..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization)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 SC0..*Reference(AU Core Diagnostic Result Observation | AU Core Diagnostic Imaging Result Observation | AU Core Pathology Result Observation)Observations
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..1Reference(Media)Reference to the image source
... conclusion S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm SC0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredhttps://healthterminologies.gov.au/fhir/ValueSet/diagnosticreportstatus-report-available-1
DiagnosticReport.categoryextensibleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/evaluation-procedure-1
DiagnosticReport.result.typeextensibleResourceType
DiagnosticReport.conclusionCodepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-dir-04errorDiagnosticReport.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
TBD TBD TBD TBD TBD

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported: