The Diagnostic Report (result) resource describes the findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations and/or specimens derived from these. A diagnostic report is the set of information that is typically provided by a diagnostic service when investigations are complete. The information can include a mix of atomic results, text reports, images, and codes. Report conclusions can be expressed as a simple text blob, structured coded data or as an attached fully formatted report such as a PDF.
Name | Card. | Type | Description & Constraints |
---|---|---|---|
DiagnosticReport | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
id | 0..1 | Id | Logical id of this artifact |
meta | 0..1 | Meta | Metadata about the resource |
implicitRules | 0..1 | Uri | A set of rules under which this content was created |
language | 0..1 | Code | Language of the resource content Binding A human language. (http://tools.ietf.org/html/bcp47) Binding Strength Required |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources |
identifier | 0..1 | Identifier | Id for external references to this report |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
use | 0..1 | Code | usual | official | temp | secondary (If known) Binding Identifies the purpose for this identifier, if known . (http://hl7.org/fhir/ValueSet/identifier-use) Binding Strength Required Example Value official |
type | 0..1 | CodeableConcept | Description of identifier Binding A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. (http://hl7.org/fhir/ValueSet/identifier-type) Binding Strength Extensible |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
coding | 0..1 | Coding | Code defined by a terminology system |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
system | 1..1 | Uri | Identity of the terminology system Example Value http://hl7.org/fhir/ValueSet/identifier-type |
version | 0..1 | String | Version of the system - if relevant |
code | 1..1 | Code | Symbol in syntax defined by the system |
display | 1..1 | String | Representation defined by the system |
userSelected | 0..1 | Boolean | If this coding was chosen directly by the user |
text | 0..1 | String | Plain text representation of the concept |
system | 1..1 | Uri | The namespace for the identifier Example Value http://www.sampleth.nhs.uk/pathology/report-identifier |
value | 1..1 | String | The value that is unique Example Value STHTPATH89000000003 |
period | 0..1 | Period | Time period when id is/was valid for use |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
start | 1..1 | DateTime | Starting time with inclusive boundary |
end | 0..1 | DateTime | End time with inclusive boundary, if not ongoing |
assigner | 0..1 | Reference (CareConnect-Organization-1) | Organization that issued id (may be just text) |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
reference | 1..1 | String | Relative URL reference Example Value Organization/223f5c66-66bf-4cea-a5d7-25ab9348b448 |
display | 0..1 | String | Text alternative for the resource Example Value Sampletown Teaching Hospitals, Pathology Services |
status | 1..1 | Code | registered | partial | final | corrected | appended | cancelled | entered-in-error Binding The status of the diagnostic report as a whole. (http://hl7.org/fhir/ValueSet/diagnostic-report-status) Binding Strength Required Example Value final |
category | 0..1 | CodeableConcept | Service category Binding Codes for diagnostic service sections. (http://snomed.info/sct) Binding Strength Example |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
coding | 0..1 | Coding | Code defined by a terminology system |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
system | 1..1 | Uri | Identity of the terminology system Example Value http://snomed.info/sct |
version | 0..1 | String | Version of the system - if relevant |
code | 1..1 | Code | Symbol in syntax defined by the system Example Value 15220000 |
display | 1..1 | String | Representation defined by the system Example Value Laboratory test |
userSelected | 0..1 | Boolean | If this coding was chosen directly by the user |
text | 0..1 | String | Plain text representation of the concept |
code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding Codes that describe Diagnostic Reports. (http://hl7.org/fhir/ValueSet/diagnostic-service-sections) Binding Strength Preferred |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
coding | 0..1 | Coding | Code defined by a terminology system |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
system | 1..1 | Uri | Identity of the terminology system Fixed Value http://hl7.org/fhir/ValueSet/diagnostic-service-sections |
version | 0..1 | String | Version of the system - if relevant |
code | 1..1 | Code | Symbol in syntax defined by the system Example Value MB |
display | 1..1 | String | Representation defined by the system Example Value Micorbiology |
userSelected | 0..1 | Boolean | If this coding was chosen directly by the user |
text | 0..1 | String | Plain text representation of the concept |
subject | 1..1 | Reference (CareConnect-Patient-1 | Group | Device | Location) | The subject of the report which is the patient |
effective[x] | 1..1 | DateTime | Period | Clinically Relevant time/time-period for report |
issued | 1..1 | Instant | DateTime this version was released |
performer | 1..1 | Reference (CareConnect-Organization-1 | CareConnect-Practitioner-1) | Responsible Diagnostic Service |
request | 0..* | Reference (DiagnosticOrder | ProcedureRequest | ReferralRequest) | What was requested |
specimen | 0..* | Reference (dds-report-specimen-1) | Specimens this report is based on |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
reference | 0..1 | String | Relative, internal or absolute URL reference |
display | 0..1 | String | Text alternative for the resource |
result | 0..* | Reference (Observation) | Observations - simple, or complex nested groups |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
reference | 0..1 | String | Relative, internal or absolute URL reference |
display | 0..1 | String | Text alternative for the resource |
imagingStudy | 0..* | Reference (ImagingStudy | ImagingObjectSelection) | Reference to full details of imaging associated with the diagnostic report |
image | 0..* | BackboneElement | Key images associated with this report |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
comment | 0..1 | String | Comment about the image (e.g. explanation) |
link | 1..1 | Reference (Media) | Reference to the image source |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
reference | 1..1 | String | Relative, internal or absolute URL reference |
display | 0..1 | String | Text alternative for the resource |
conclusion | 0..1 | String | Clinical Interpretation of test results Example Value Immune to Hepatitis B. Immunity due to vaccination. |
codedDiagnosis | 0..* | CodeableConcept | Codes for the conclusion Binding Diagnoses codes provided as adjuncts to the report. (http://hl7.org/fhir/ValueSet/clinical-findings) Binding Strength Example |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
coding | 0..1 | Coding | Code defined by a terminology system |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
system | 1..1 | Uri | Identity of the terminology system Fixed Value http://hl7.org/fhir/ValueSet/clinical-findings |
version | 0..1 | String | Version of the system - if relevant |
code | 1..1 | Code | Symbol in syntax defined by the system Example Value 271511000 |
display | 1..1 | String | Representation defined by the system Example Value Hepatitis B immune |
userSelected | 0..1 | Boolean | If this coding was chosen directly by the user |
text | 0..1 | String | Plain text representation of the concept |
presentedForm | 0..* | Attachment | Entire report as issued |
id | 0..1 | Id | xml:id (or equivalent in JSON) |
contentType | 0..1 | Code | Mime type of the content, with charset etc. Binding The mime type of an attachment. Any valid mime type is allowed. (http://www.rfc-editor.org/bcp/bcp13.txt) Binding Strength Required Example Value text/plain; charset=UTF-8, image/png |
language | 0..1 | Code | Human language of the content (BCP-47) Binding A human language. (https://fhir.hl7.org.uk/ValueSet/CareConnect-HumanLanguage-1) Binding Strength Required Example Value English |
data | 0..1 | Base64Binary | Data inline, base64ed |
url | 0..1 | Uri | Uri where the data can be found Example Value http://www.sampleth.nhs.uk/pathology/logo-small.png |
size | 0..1 | UnsignedInt | Number of bytes of content (if url provided) |
hash | 0..1 | Base64Binary | Hash of the data (sha-1, base64ed) |
title | 0..1 | String | Label to display in place of the data Example Value Official Corporate Logo |
creation | 0..1 | DateTime | Date attachment was first created |
Path | Name | Binding Strength | ValueSet |
---|---|---|---|
DiagnosticReport.language | language | Required | http://tools.ietf.org/html/bcp47 |
DiagnosticReport.identifier.use | use | Required | http://hl7.org/fhir/ValueSet/identifier-use |
DiagnosticReport.identifier.type | type | Extensible | http://hl7.org/fhir/ValueSet/identifier-type |
DiagnosticReport.status | status | Required | http://hl7.org/fhir/ValueSet/diagnostic-report-status |
DiagnosticReport.category | category | Example | http://snomed.info/sct |
DiagnosticReport.code | code | Preferred | http://hl7.org/fhir/ValueSet/diagnostic-service-sections |
DiagnosticReport.codedDiagnosis | codedDiagnosis | Example | http://hl7.org/fhir/ValueSet/clinical-findings |
DiagnosticReport.presentedForm.contentType | contentType | Required | http://www.rfc-editor.org/bcp/bcp13.txt |
DiagnosticReport.presentedForm.language | language | Required | https://fhir.hl7.org.uk/ValueSet/CareConnect-HumanLanguage-1 |
DDS-Report-1