DataStandardsWales-DiagnosticReport

The DiagnosticReport profile contains 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.

A direct link to the Data Standards Wales asset can be accessed here - Data Standards Wales Diagnostic Report

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Mandatory and Must Support Data Elements

Refer to the Mandatory and Must Support page for guidance on how these elements should be interpreted.

Each DiagnosticReport must have:

  1. A status
  2. A code describing the type of report
  3. A patient

Each DiagnosticReport must support:

  1. The encounter the report occurred within
  2. A category
  3. An effective timestamp
  4. An issued date for this report version
  5. An author (actor) producing the report
  6. A reference to one or more specimens
  7. A reference to one or more test results
  8. A reference to one or more images
  9. A reference to the full report (presentedForm)

*see Implementation Guidance for the identifier element below

Implementation Guidance

  • The DiagnosticReport.status field SHALL be populated to indicate whether the report is preliminary, partial, final.

  • The DiagnosticReport.code field SHALL be populated.

  • Depending on the report type the DiagnosticReport.result, DiagnosticReport.imagingStudy or DiagnosticReport.presentedForm SHALL be populated according to guidance set out in the Diagnostic Reports Guidance page.

  • The DiagnosticReport.identifier field SHOULD contain all available identifiers. Typical identifiers include:
    • Identifiers assigned to the DiagnosticReport by the Welsh Results and Reporting Service
    • Other identifiers assigned by a hospital PAS or other clinical system.

  • The DiagnosticReport.category field SHOULD be populated. E.g.:
    • RAD - (Radiology)
    • MB - (Microbiology)

  • The DiagnosticReport.effective field SHOULD be populated. The diagnostically relevant time (known as the “effective time” and typically the time of the procedure)*

  • The DiagnosticReport.issued field SHOULD be populated. The time this version of the report was made available*

Example DiagnosticReports

The following example resources are provided within this guide:

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching by an DiagnosticReport identifier using the identifier search parameter:

    GET [base]/DiagnosticReport?identifier={system|}[code]
    

    Example:

    1. GET [base]/DiagnosticReport?identifier=https://fhir.nhs.wales/Id/wrrs-report-identifier|1000122
      Implementation Notes: Fetches a bundle containing any DiagnosticReport resources matching the identifier (how to search by token).

  2. SHALL support searching using the patient search parameter:

    GET [base]/DiagnosticReport?patient={Type/}[id]
    

    Example:

    1. GET [base]/DiagnosticReport?patient=Patient/NN046351-149
    2. GET [base]/DiagnosticReport?patient:identifier=https://fhir.nhs.uk/Id/nhs-number|9912003444
      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient (how to search by reference)

  3. SHALL support searching using the combination of the patient and code search parameters:

    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
    

    Example:

    1. GET \[base\]/DiagnosticReport?patient=23&code=https://fhir.nhs.wales/Id/wrrs-provider-system-code|FBC
    2. GET \[base\]/DiagnosticReport?patient:identifier=https://fhir.nhs.uk/Id/nhs-number|9912003444&code=https://fhir.nhs.wales/Id/wrrs-provider-system-code|FBC,https://fhir.nhs.wales/Id/wrrs-provider-system-code|LFT
      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and DiagnosticReport code(s). SHOULD support search by multiple report codes. The DiagnosticReport code parameter searches `DiagnosticReport.code only. (how to search by reference and how to search by token)

Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and status search parameters:

    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)
    GET [base]/DiagnosticReport?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}
    

    Example:

    1. GET \[base\]/DiagnosticReport?patient=23&status=final
      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and status (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and category and date search parameters:

    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)
    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
    

    Example:

    1. GET [base]/DiagnosticReport?Patient=Patient/23&category=https://fhir.nhs.wales/Id/wrrs-provider-type-code|P&date=ge2010-01-14T00:00:00Z
      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code specified in Data Standards Wales DiagnosticReport Category Codes (how to search by reference and how to search by token and how to search by date)

  3. SHOULD support searching using the combination of the patient and code and date search parameters:

    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)
    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
    

    Example:

    1. GET [base\]/DiagnosticReport?Patient=Patient/23&code=https://fhir.nhs.wales/Id/wrrs-provider-system-code|FBC&date=ge2010-01-14T00:00:00Z
      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). (how to search by reference and how to search by token and how to search by date)