Diagnostic Reports

Guidance

This page describes how the Data Standards Wales DiagnosticReport Profile supports the following types of reports that would be returned against a patient within NHS Wales. The following are expected use cases for the Data Standards Wales DiagnosticReport profile:

  • Laboratory result(s)
  • An imaging study report
  • A diagnostic report where the result is contained within an attached document (PDF or similar)

This implementation guidance includes the following profiles for diagnostic data:

Clinical Scenario: Laboratory/Pathology Result

Overview

Pathology is the most prevalent of the results in the Welsh Results & Reporting Service. Pathology covers many departmental areas:

  • Blood Sciences (BSC)
  • Bio-Chemistry (CHM)
  • Immunology (IMM)
  • Microbiology (MIC)
  • Histopathology (HIS)
  • Haematology
  • Screening
  • Andrology

Implementation Guidance

Please refer to the Data Standards Wales DiagnosticReport for Laboratory Results Profile page for general guidance.

For Pathology results in NHS Wales:

  • The DiagnosticReport.meta.profile field SHALL be https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DiagnosticReport-Lab

  • The DiagnosticReport.result field SHALL be populated
    • This field will be populated with the Observation Group containing 1 or multiple ObservationResults as Members.

Scenario 1: Single Panel

  • Status: Final
  • Security Label: Normal
  • Category: Pathology
  • Code: FBC
  • Result: FBC (Full Blood Count)

Logical Model

The diagram below shows the typical relationship between NHS Wales DiagnosticReport and Observations.


Important: Single panel approach for Laboratory DiagnosticReports needs review and approval.

Example Result

Click here for an Example of a Diagnostic Report returning Pathology single panel Full Blood Count Blood Sciences result.

Scenario 2: Multiple Panel

  • Status: Final
  • Security Label: Normal
  • Category: Pathology
  • Code: Pathology
  • Results: ACE (Angiotensin Converting Enzyme), LFT (Liver Function Test)

Logical Model

The diagram below shows the typical relationship between NHS Wales DiagnosticReport and Observations.


Click here for an Example of a Diagnostic Report returning Pathology multiple panel Blood Sciences result.

Overview

Radiology Imaging results can include the following types

  • X-Rays
  • Computed Tomography (CT)
  • Magnetic Resonance Tomography (MRI)
  • Nuclear Medicine Positron Emission Tomography (PET)
  • Ultrasound

Implementation Guidance

Please refer to the Data Standards Wales DiagnosticReport Profile page for general guidance.

For Radiology Imaging results in NHS Wales:

  • The DiagnosticReport.meta.profile field SHALL be https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DiagnosticReport

  • The DiagnosticReport.imagingStudy field SHALL be populated

Scenario

  • Status: Final
  • Security Label: Normal
  • Category: Radiology
  • Code: CT Abdomen

Logical Model

The diagram below shows the typical relationship between NHS Wales DiagnosticReport and Imaging .


Example Results

  • Click here for an example of a Diagnostic Report returning a CT Abdomen ImagingStudy reference.
  • Click here for an example of the referenced ImagingStudy.
  • Click here for an example of the referenced FHIR Endpoint.

Clinical Scenario: Cardiology Result (Attached Document)

Overview

Departments that can send binary attachments within NHS Wales to the Welsh Results & Reporting Service system are:

  • Blood Science
  • Cardiology
  • Endoscopy
  • Genetics
  • Haematology
  • Histology
  • Microbiology
  • Neurophysiology
  • Radiology
  • Respiratory
  • Urology

Implementation Guidance

Please refer to the Data Standards Wales DiagnosticReport Profile page for general guidance.

For DiagnosticReport results with Attached Documents in NHS Wales:

  • The DiagnosticReport.meta.profile field SHALL be https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DiagnosticReport

  • The DiagnosticReport.presentedForm field SHALL be populated
    • The DiagnosticReport.presentedForm.contentType field SHALL be populated
    • The DiagnosticReport.presentedForm.data field SHALL be populated with base64 string representation of the document
    • The DiagnosticReport.presentedForm.title field SHALL be populated

Scenario 1

  • Status: Final
  • Security Label: Normal
  • Category: Cardiology
  • Encounter: Emergency Admission
  • Result: ECG

Logical Model

The diagram below shows the typical relationship between NHS Wales DiagnosticReport and presentedForm .


Example Result

Click here for an Example of a Diagnostic Report returning a Cardiology ECG report as presentedForm.

Scenario 2

  • Status: Final
  • Security Label: Normal
  • Category: Cardiology
  • Result: Stress Test

Example Result

Click here for an Example of a Diagnostic Report returning a Cardiology Stress Test report as presentedForm.