WARNING
This guidance is under active development by NHS England and content may be added or updated on a regular basis. The implementation guide is currently in draft and SHOULD NOT be used for development or implementation without consulting the NHS England Pathology Standards and Implementation team.PATH-R4-28: UKCore-DiagnosticReport-Lab Snippets
An example of how each key UKCore-DiagnosticReport-Lab
data element may be populated is provided below. Please note that the examples are provided to illustrate individual data element usage; the full set of data elements may not necessarily be consistent with one another or illustrate a single, complete clinical scenario.
Refer to the UKCore-DiagnosticReport-Lab profile definition for a detailed description of the supported data elements.
<DiagnosticReport xmlns="http://hl7.org/fhir"> <id value="Pathology-DiagnosticReport-Lab-Sn-Example" /> <!-- ***************extension end*************** --> <!-- The canonical URL for the UKCore-DiagnosticReport-Lab profile. --> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-DiagnosticReport-Lab" /> </meta> <!-- ***************extension start*************** --> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note"> <valueAnnotation> <authorReference> <reference value="e5abf65d-ff1e-4a63-be9d-d12e71cbdf6a" /> </authorReference> <time value="2022-02-09T11:17:00+00:00" /> <text value="Contact Dr Jones on receipt of results." /> </valueAnnotation> </extension> <!-- A business identifier supplied by the laboratory that produced the test report. --> <identifier> <system value="http://Y8J7D-pathlab001.com/report" /> <value value="REP-20220209-001369" /> </identifier> <!-- Reference to the ServiceRequest that contains details of the test request that was made. --> <basedOn> <reference value="urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac" /> <type value="ServiceRequest" /> </basedOn> <!-- The status of the test report. --> <status value="final" /> <category> <!-- The general type of test report. --> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0074" /> <code value="LAB" /> <display value="Laboratory" /> </coding> <coding> <display value="Medical microbiology" /> </coding> </category> <!-- A code that describes the report. Populated with the following fixed value. --> <code> <coding> <system value="http://snomed.info/sct" /> <code value="721981007" /> <display value="Diagnostic studies report" /> </coding> </code> <!-- Reference to the subject that the test report relates to. --> <subject> <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" /> <display value="MOXEY, Judy" /> </subject> <!-- The date and time that the test report was issued. --> <issued value="2022-02-09T11:17:00+00:00" /> <!-- Reference(s) to the entity/entities that produced the test report. --> <performer> <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" /> <display value="TD008362 PATH LAB 001" /> </performer> <!-- Reference(s) to the specimen(s) used for testing. --> <specimen> <reference value="urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d" /> </specimen> <!-- Reference(s) to the results included in the test report. --> <!-- This may contain references to individual test results, test groups or a combination of these. --> <result> <reference value="urn:uuid:ad717ae8-cb35-4d66-ba51-e22a76b1d158" /> </result> <!-- A clinical interpretation/summary of the test results in a text format. --> <conclusion value="Blood culture tested positive on staphylococcus aureus." /> <!-- A coded finding of the test report. --> <conclusionCode> <coding> <system value="http://snomed.info/sct" /> <code value="428763004" /> <display value="Bacteraemia caused by Staphylococcus aureus" /> </coding> </conclusionCode> </DiagnosticReport>
{ "resourceType": "DiagnosticReport", "id": "Pathology-DiagnosticReport-Lab-Sn-Example", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-DiagnosticReport-Lab" ] }, "extension": [ { "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note", "valueAnnotation": { "authorReference": { "reference": "e5abf65d-ff1e-4a63-be9d-d12e71cbdf6a" }, "time": "2022-02-09T11:17:00+00:00", "text": "Contact Dr Jones on receipt of results." } } ], "identifier": [ { "system": "http://Y8J7D-pathlab001.com/report", "value": "REP-20220209-001369" } ], "basedOn": [ { "reference": "urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac", "type": "ServiceRequest" } ], "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" }, { "display": "Medical microbiology" } ] } ], "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "721981007", "display": "Diagnostic studies report" } ] }, "subject": { "reference": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4", "display": "MOXEY, Judy" }, "issued": "2022-02-09T11:17:00+00:00", "performer": [ { "reference": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338", "display": "TD008362 PATH LAB 001" } ], "specimen": [ { "reference": "urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d" } ], "result": [ { "reference": "urn:uuid:ad717ae8-cb35-4d66-ba51-e22a76b1d158" } ], "conclusion": "Blood culture tested positive on staphylococcus aureus.", "conclusionCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "428763004", "display": "Bacteraemia caused by Staphylococcus aureus" } ] } ] }
DiagnosticReport.id[0] | Pathology-DiagnosticReport-Lab-Sn-Example |
DiagnosticReport.meta[0].profile[0] | https://fhir.hl7.org.uk/StructureDefinition/UKCore-DiagnosticReport-Lab |
DiagnosticReport.extension[0].url[0] | http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note |
DiagnosticReport.extension[0].value[0].author[0].reference[0] | e5abf65d-ff1e-4a63-be9d-d12e71cbdf6a |
DiagnosticReport.extension[0].value[0].time[0] | 2022-02-09T11:17:00+00:00 |
DiagnosticReport.extension[0].value[0].text[0] | Contact Dr Jones on receipt of results. |
DiagnosticReport.identifier[0].system[0] | http://Y8J7D-pathlab001.com/report |
DiagnosticReport.identifier[0].value[0] | REP-20220209-001369 |
DiagnosticReport.basedOn[0].reference[0] | urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac |
DiagnosticReport.basedOn[0].type[0] | ServiceRequest |
DiagnosticReport.status[0] | final |
DiagnosticReport.category[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v2-0074 |
DiagnosticReport.category[0].coding[0].code[0] | LAB |
DiagnosticReport.category[0].coding[0].display[0] | Laboratory |
DiagnosticReport.category[0].coding[1].display[0] | Medical microbiology |
DiagnosticReport.code[0].coding[0].system[0] | http://snomed.info/sct |
DiagnosticReport.code[0].coding[0].code[0] | 721981007 |
DiagnosticReport.code[0].coding[0].display[0] | Diagnostic studies report |
DiagnosticReport.subject[0].reference[0] | urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4 |
DiagnosticReport.subject[0].display[0] | MOXEY, Judy |
DiagnosticReport.issued[0] | 2022-02-09T11:17:00+00:00 |
DiagnosticReport.performer[0].reference[0] | urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338 |
DiagnosticReport.performer[0].display[0] | TD008362 PATH LAB 001 |
DiagnosticReport.specimen[0].reference[0] | urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d |
DiagnosticReport.result[0].reference[0] | urn:uuid:ad717ae8-cb35-4d66-ba51-e22a76b1d158 |
DiagnosticReport.conclusion[0] | Blood culture tested positive on staphylococcus aureus. |
DiagnosticReport.conclusionCode[0].coding[0].system[0] | http://snomed.info/sct |
DiagnosticReport.conclusionCode[0].coding[0].code[0] | 428763004 |
DiagnosticReport.conclusionCode[0].coding[0].display[0] | Bacteraemia caused by Staphylococcus aureus |