description: Base StructureDefinition for DiagnosticReport Resource package_name: hl7.fhir.r2b.examples derivation: specialization name: DiagnosticReport type: null elements: category: isModifier: false short: Service category index: 2 comments: 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. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.category} isSummary: true conclusion: isModifier: false short: Clinical Interpretation of test results index: 19 comments: Typically, a report is either [all data, no narrative (e.g. Core lab)] or [a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density)], or [all narrative (e.g. typical imaging report, histopathology)]. In all of these cases, the narrative goes in "text". type: string mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.conclusion} isSummary: false request: isModifier: false short: What was requested index: 12 comments: '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.' type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.request} isSummary: false encounter: isModifier: false short: Health care event when test ordered type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.encounter} isSummary: true index: 5 specimen: isModifier: false short: Specimens this report is based on index: 13 comments: 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. type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.specimen} isSummary: false effectiveDateTime: isModifier: false short: Clinically Relevant time/time-period for report index: 8 comments: 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. type: dateTime mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: 'DiagnosticReport.effective[x]'} choiceOf: effective isSummary: true status: isModifier: true short: registered | partial | final | corrected | appended | cancelled | entered-in-error index: 1 comments: This is labeled as "Is Modifier" because applications need to take appropriate action if a report is withdrawn. type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.status} isSummary: true result: isModifier: false short: Observations - simple, or complex nested groups index: 14 type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.result} isSummary: false effective: isModifier: false short: Clinically Relevant time/time-period for report index: 7 comments: 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. mustSupport: false choices: [effectiveDateTime, effectivePeriod] maxLength: 0 base: {max: '1', min: 0, path: 'DiagnosticReport.effective[x]'} isSummary: true code: isModifier: false short: Name/Code for this diagnostic report index: 3 type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.code} isSummary: true identifier: isModifier: false short: Id for external references to this report index: 0 type: Identifier mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.identifier} isSummary: true image: isModifier: false short: Key images associated with this report index: 16 type: BackboneElement mustSupport: false array: true elements: comment: isModifier: false short: Comment about the image (e.g. explanation) index: 17 comments: 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. type: string mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.image.comment} isSummary: false link: isModifier: false short: Reference to the image source index: 18 type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.image.link} isSummary: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.image} required: [link] isSummary: true issued: isModifier: false short: DateTime this version was released index: 10 comments: 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. type: instant mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.issued} isSummary: true presentedForm: isModifier: false short: Entire report as issued index: 21 comments: '"application/pdf" is recommended as the most reliable and interoperable in this context.' type: Attachment mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.presentedForm} isSummary: false imagingStudy: isModifier: false short: Reference to full details of imaging associated with the diagnostic report index: 15 comments: ImagingStudy and ImageObjectStudy 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. type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.imagingStudy} isSummary: false codedDiagnosis: isModifier: false short: Codes for the conclusion index: 20 type: CodeableConcept mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DiagnosticReport.codedDiagnosis} isSummary: false subject: isModifier: false short: The subject of the report, usually, but not always, the patient index: 4 type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.subject} isSummary: true performer: isModifier: false short: Responsible Diagnostic Service index: 11 comments: This is not necessarily the source of the atomic data items. It is the entity that takes responsibility for the clinical report. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DiagnosticReport.performer} isSummary: true effectivePeriod: isModifier: false short: Clinically Relevant time/time-period for report index: 9 comments: 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. type: Period mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: 'DiagnosticReport.effective[x]'} choiceOf: effective isSummary: true package_version: 1.4.0 class: resource kind: resource url: http://hl7.org/fhir/StructureDefinition/DiagnosticReport base: http://hl7.org/fhir/StructureDefinition/DomainResource version: null required: [effectiveDateTime, issued, effectivePeriod, status, subject, code, effective, performer]