Data Structure
Diagnostic Report
Object name: diagnostic_report
HL7 | Name | Type | M/O | Description and constraints | HL7 vs eHealth comparison result | Status |
|---|---|---|---|---|---|---|
| identifier : { Identifier } // Business identifier for report | id | uuid | M | Ok | ||
| basedOn : [{ Reference(CarePlan | ImmunizationRecommendation| MedicationRequest | NutritionOrder | ServiceRequest) }] // What was requested | based_on | [Reference(ServiceRequest)] | O | |||
| status : { code } // registered | partial | preliminary | final + DiagnosticReportStatus (Required) | status | dictionary | M | |||
| category: [{ CodeableConcept }] // Service category Diagnostic Service Section Codes (Example) | category | codeable_concept | O | 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. | ||
| code: { CodeableConcept } // Name/Code for this diagnostic report LOINC Diagnostic Report Codes (Preferred) | code | codeable_concept | M | Ok | ||
| subject: { Reference(Patient | Group | Device | Location) // The subject of the report - usually, but not always, the patient | subject | uuid | M | 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. | HL7: optional | |
| encounter: { Reference(Encounter) } // Health care event when test ordered | encounter | Reference(Encounter) | O | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about 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). | ||
| effective[x]: { } // Clinically relevant time/time-period for report | effective | effective_at | O | 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 | e-health: complex type "effective_at" is used instead of HL7 suggested type | |
| effectiveDateTime: { dateTime } | O | e-health: no Implementation (covered by effective) | ||||
| effectivePeriod: { Period } | O | e-health: no Implementation (covered by effective) | ||||
| issued: { instant } // DateTime this version was made | issued | date_time | O | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified 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. OUGHT to be with time zone specified | e-health: date_time data type is implemented | |
| performer: [{ Reference(Practitioner | PractitionerRole | Organization| CareTeam) }] // Responsible Diagnostic Service | performer | Reference (Organization) | O | The diagnostic service that is responsible for issuing the report. 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. | e-health: only reference to Organization is implemented | |
| - | performer_employee | string | O | Need to know whom to contact if there are queries about the clinical report | HL7: no such attribute | |
| resultsInterpreter: [{ Reference(Practitioner | PractitionerRole | Organization| CareTeam) }] // Primary result interpreter | O | 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. Might not be the same entity that takes responsibility for the clinical report. | e-health: no implementation (untill imaging study diagnostic reports are implemented) | |||
| specimen: [{ Reference(Specimen) }] // Specimens this report is based on | O | e-health: no implementation | ||||
| result: [{ Reference(Observation) }] // Observations | result | [Reference(Observation)] | O | Observations that are part of this diagnostic report | ||
| imagingStudy: [{ Reference(ImagingStudy) }] // Reference to full details of imaging associated with the diagnostic report | O | 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. 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. | e-health: no implementation | |||
| media: [{ BackboneElement }] // Key images associated with this report | O | 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). | e-health: no implementation | |||
| comment: { string } // Comment about the image (e.g. explanation) | O | 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. 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. | e-health: no implementation | |||
| link: { Reference(Media) } // Reference to the image source | M | Reference to the image source. | e-health: no implementation | |||
conclusion: { string } // Clinical conclusion (interpretation) of test results | O | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | e-health: no implementation | |||
| conclusionCode: { CodeableConcept } // Codes for the clinical conclusion of test results SNOMED CT Clinical Findings (Example) | O | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | e-health: no implementation | |||
| presentedForm: { Attachment } // Entire report as issued | presented_form | attachment  | O | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. |