Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | DomainResource | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||
identifier | Σ | 0..* | Identifier | Id for external references to this report |
status | ?! Σ | 1..1 | code | registered | partial | final | corrected | appended | cancelled | entered-in-error
DiagnosticReportStatus ( Required) |
category | Σ | 0..1 | CodeableConcept | Service category
Diagnostic Service Section Codes ( Example) |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report
LOINC Diagnostic Report Codes ( Preferred) |
subject | Σ | 1..1 | Reference( Patient | Group | Device | Location) | The subject of the report, usually, but not always, the patient |
encounter | Σ | 0..1 | Reference( Encounter) | Health care event when test ordered |
effective[x] | Σ | 1..1 | Clinically Relevant time/time-period for report | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 1..1 | instant | DateTime this version was released |
performer | Σ | 1..1 | Reference( Practitioner | Organization) | Responsible Diagnostic Service |
request | 0..* | Reference( DiagnosticOrder | ProcedureRequest | ReferralRequest) | What was requested | |
specimen | 0..* | Reference( Specimen) | Specimens this report is based on | |
result | 0..* | Reference( Observation) | Observations - simple, or complex nested groups | |
imagingStudy | 0..* | Reference( ImagingStudy | ImagingObjectSelection) | Reference to full details of imaging associated with the diagnostic report | |
image | Σ | 0..* | BackboneElement | Key images associated with this report |
comment | 0..1 | string | Comment about the image (e.g. explanation) | |
link | Σ | 1..1 | Reference( Media) | Reference to the image source |
conclusion | 0..1 | string | Clinical Interpretation of test results | |
codedDiagnosis | 0..* | CodeableConcept | Codes for the conclusion
SNOMED CT Clinical Findings ( Example) |
|
presentedForm | 0..* | Attachment | Entire report as issued | |
Documentation for this format |