{
"description": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.",
"_filename": "DiagnosticReport.json",
"package_name": "hl7.fhir.r4.id.core",
"date": "2019-11-01T09:29:23+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2021-12-31T09:12:48.701+00:00"
},
"publisher": "Health Level Seven International (Orders and Observations)",
"fhirVersion": "4.0.1",
"purpose": "To support reporting for any diagnostic report into a clinical data repository.",
"name": "DiagnosticReport",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
} ],
"abstract": false,
"type": "DiagnosticReport",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "0.1.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Clinical.Diagnostics"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 3
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "oo"
} ],
"status": "draft",
"id": "17b230c3-9aa6-4657-b791-3187353f7c36",
"kind": "resource",
"url": "https://fhir.kemkes.go.id/r4/StructureDefinition/DiagnosticReport",
"version": "4.0.1",
"differential": {
"element": [ {
"id": "DiagnosticReport",
"path": "DiagnosticReport",
"alias": [ "Report", "Test", "Result", "Results", "Labs", "Laboratory" ],
"short": "A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports",
"comment": "This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.",
"mapping": [ {
"map": "Event",
"identity": "workflow"
}, {
"map": "ORU -> OBR",
"identity": "v2"
}, {
"map": "Observation[classCode=OBS, moodCode=EVN]",
"identity": "rim"
} ],
"definition": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports."
}, {
"path": "DiagnosticReport.identifier",
"requirements": "Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.",
"definition": "Identifiers assigned to this report by the performer or other systems.",
"short": "Business identifier for report",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
}, {
"map": "OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4",
"identity": "v2"
}, {
"map": "id",
"identity": "rim"
} ],
"type": [ {
"code": "Identifier"
} ],
"alias": [ "ReportID", "Filler ID", "Placer ID" ],
"id": "DiagnosticReport.identifier",
"comment": "Usually assigned by the Information System of the diagnostic service provider (filler id).",
"isSummary": true
}, {
"path": "DiagnosticReport.basedOn",
"requirements": "This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.",
"definition": "Details concerning a service requested.",
"short": "What was requested",
"mapping": [ {
"map": "Event.basedOn",
"identity": "workflow"
}, {
"map": "ORC? OBR-2/3?",
"identity": "v2"
}, {
"map": "outboundRelationship[typeCode=FLFS].target",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CarePlan", "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ],
"alias": [ "Request" ],
"id": "DiagnosticReport.basedOn",
"comment": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports."
}, {
"path": "DiagnosticReport.status",
"requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.",
"min": 1,
"definition": "The status of the diagnostic report.",
"isModifier": true,
"short": "registered | partial | preliminary | final +",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
}, {
"map": "OBR-25 (not 1:1 mapping)",
"identity": "v2"
}, {
"map": "statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\"",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosticReportStatus"
} ],
"description": "The status of the diagnostic report."
},
"max": "1",
"id": "DiagnosticReport.status",
"isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"path": "DiagnosticReport.category",
"definition": "A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.",
"short": "Service category",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": "OBR-24",
"identity": "v2"
}, {
"map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/diagnostic-service-sections",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosticServiceSection"
} ],
"description": "Codes for diagnostic service sections."
},
"alias": [ "Department", "Sub-department", "Service", "Discipline" ],
"id": "DiagnosticReport.category",
"comment": "Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.",
"isSummary": true
}, {
"path": "DiagnosticReport.code",
"min": 1,
"definition": "A code or name that describes this diagnostic report.",
"short": "Name/Code for this diagnostic report",
"mapping": [ {
"map": "Event.code",
"identity": "workflow"
}, {
"map": "FiveWs.what[x]",
"identity": "w5"
}, {
"map": "OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)",
"identity": "v2"
}, {
"map": "code",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/report-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosticReportCodes"
} ],
"description": "Codes that describe Diagnostic Reports."
},
"alias": [ "Type" ],
"max": "1",
"id": "DiagnosticReport.code",
"isSummary": true
}, {
"path": "DiagnosticReport.subject",
"requirements": "SHALL know the subject context.",
"definition": "The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.",
"short": "The subject of the report - usually, but not always, the patient",
"mapping": [ {
"map": "Event.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "PID-3 (no HL7 v2 mapping for Group or Device)",
"identity": "v2"
}, {
"map": "participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"alias": [ "Patient" ],
"max": "1",
"id": "DiagnosticReport.subject",
"isSummary": true
}, {
"path": "DiagnosticReport.encounter",
"requirements": "Links the request to the Encounter context.",
"definition": "The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.",
"short": "Health care event when test ordered",
"mapping": [ {
"map": "Event.encounter",
"identity": "workflow"
}, {
"map": "FiveWs.context",
"identity": "w5"
}, {
"map": "PV1-19",
"identity": "v2"
}, {
"map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"alias": [ "Context" ],
"max": "1",
"id": "DiagnosticReport.encounter",
"comment": "This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).",
"isSummary": true
}, {
"path": "DiagnosticReport.effective[x]",
"requirements": "Need to know where in the patient history to file/present this report.",
"definition": "The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.",
"short": "Clinically relevant time/time-period for report",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.done[x]",
"identity": "w5"
}, {
"map": "OBR-7",
"identity": "v2"
}, {
"map": "effectiveTime",
"identity": "rim"
} ],
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"alias": [ "Observation time", "Effective Time", "Occurrence" ],
"max": "1",
"id": "DiagnosticReport.effective[x]",
"comment": "If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.",
"isSummary": true
}, {
"path": "DiagnosticReport.issued",
"requirements": "Clinicians need to be able to check the date that the report was released.",
"definition": "The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.",
"short": "DateTime this version was made",
"mapping": [ {
"map": "FiveWs.recorded",
"identity": "w5"
}, {
"map": "OBR-22",
"identity": "v2"
}, {
"map": "participation[typeCode=VRF or AUT].time",
"identity": "rim"
} ],
"type": [ {
"code": "instant"
} ],
"alias": [ "Date published", "Date Issued", "Date Verified" ],
"max": "1",
"id": "DiagnosticReport.issued",
"comment": "May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.",
"isSummary": true
}, {
"path": "DiagnosticReport.performer",
"requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.",
"definition": "The diagnostic service that is responsible for issuing the report.",
"short": "Responsible Diagnostic Service",
"mapping": [ {
"map": "Event.performer.actor",
"identity": "workflow"
}, {
"map": "FiveWs.actor",
"identity": "w5"
}, {
"map": "PRT-8 (where this PRT-4-Participation = \"PO\")",
"identity": "v2"
}, {
"map": ".participation[typeCode=PRF]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/CareTeam" ]
} ],
"alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company", "Authorized by", "Director" ],
"id": "DiagnosticReport.performer",
"comment": "This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.",
"isSummary": true
}, {
"path": "DiagnosticReport.resultsInterpreter",
"requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.",
"definition": "The practitioner or organization that is responsible for the report's conclusions and interpretations.",
"short": "Primary result interpreter",
"mapping": [ {
"map": "Event.performer.actor",
"identity": "workflow"
}, {
"map": "FiveWs.actor",
"identity": "w5"
}, {
"map": "OBR-32, PRT-8 (where this PRT-4-Participation = \"PI\")",
"identity": "v2"
}, {
"map": ".participation[typeCode=PRF]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/CareTeam" ]
} ],
"alias": [ "Analyzed by", "Reported by" ],
"id": "DiagnosticReport.resultsInterpreter",
"comment": "Might not be the same entity that takes responsibility for the clinical report.",
"isSummary": true
}, {
"id": "DiagnosticReport.specimen",
"path": "DiagnosticReport.specimen",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Specimen" ]
} ],
"short": "Specimens this report is based on",
"comment": "If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.",
"mapping": [ {
"map": "SPM",
"identity": "v2"
}, {
"map": "participation[typeCode=SBJ]",
"identity": "rim"
} ],
"definition": "Details about the specimens on which this diagnostic report is based.",
"requirements": "Need to be able to report information about the collected specimens on which the report is based."
}, {
"path": "DiagnosticReport.result",
"requirements": "Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.",
"definition": "[Observations](observation.html) that are part of this diagnostic report.",
"short": "Observations",
"mapping": [ {
"map": "OBXs",
"identity": "v2"
}, {
"map": "outboundRelationship[typeCode=COMP].target",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ]
} ],
"alias": [ "Data", "Atomic Value", "Result", "Atomic result", "Data", "Test", "Analyte", "Battery", "Organizer" ],
"id": "DiagnosticReport.result",
"comment": "Observations can contain observations."
}, {
"id": "DiagnosticReport.imagingStudy",
"path": "DiagnosticReport.imagingStudy",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ImagingStudy" ]
} ],
"short": "Reference to full details of imaging associated with the diagnostic report",
"comment": "ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.",
"mapping": [ {
"map": "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]",
"identity": "rim"
} ],
"definition": "One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images."
}, {
"path": "DiagnosticReport.media",
"requirements": "Many diagnostic services include images in the report as part of their service.",
"definition": "A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).",
"short": "Key images associated with this report",
"mapping": [ {
"map": "OBX?",
"identity": "v2"
}, {
"map": "outboundRelationship[typeCode=COMP].target",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"alias": [ "DICOM", "Slides", "Scans" ],
"id": "DiagnosticReport.media",
"isSummary": true
}, {
"path": "DiagnosticReport.media.comment",
"requirements": "The provider of the report should make a comment about each image included in the report.",
"definition": "A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.",
"short": "Comment about the image (e.g. explanation)",
"mapping": [ {
"map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "DiagnosticReport.media.comment",
"comment": "The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion."
}, {
"path": "DiagnosticReport.media.link",
"min": 1,
"definition": "Reference to the image source.",
"short": "Reference to the image source",
"mapping": [ {
"map": ".value.reference",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Media" ]
} ],
"max": "1",
"id": "DiagnosticReport.media.link",
"isSummary": true
}, {
"path": "DiagnosticReport.conclusion",
"requirements": "Need to be able to provide a conclusion that is not lost among the basic result data.",
"definition": "Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.",
"short": "Clinical conclusion (interpretation) of test results",
"mapping": [ {
"map": "OBX",
"identity": "v2"
}, {
"map": "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "Report" ],
"max": "1",
"id": "DiagnosticReport.conclusion"
}, {
"id": "DiagnosticReport.conclusionCode",
"path": "DiagnosticReport.conclusionCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Codes for the clinical conclusion of test results",
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/clinical-findings",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjunctDiagnosis"
} ],
"description": "Diagnosis codes provided as adjuncts to the report."
},
"mapping": [ {
"map": "OBX",
"identity": "v2"
}, {
"map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)",
"identity": "rim"
} ],
"definition": "One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report."
}, {
"id": "DiagnosticReport.presentedForm",
"path": "DiagnosticReport.presentedForm",
"type": [ {
"code": "Attachment"
} ],
"short": "Entire report as issued",
"comment": "\"application/pdf\" is recommended as the most reliable and interoperable in this context.",
"mapping": [ {
"map": "OBX",
"identity": "v2"
}, {
"map": "text (type=ED)",
"identity": "rim"
} ],
"definition": "Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.",
"requirements": "Gives laboratory the ability to provide its own fully formatted report for clinical fidelity."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/orders/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}