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:
- Data Standards Wales DiagnosticReport Profile
- Data Standards Wales DiagnosticReport Profile for Laboratory Results
- Data Standards Wales Observation Profile
- Data Standards Wales Observation Profile for Laboratory Result
- Data Standards Wales ImagingStudy Profile
- Data Standards Wales ServiceRequest Profile
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.
- 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.
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
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
- The
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.