Reports
All free texts from the EMR are bundled in this category. Think for example of surgery reports, radiology reports, pathology reports, discharge letters, referral letters, consultation notes, etc. Forms with questions that have a textual answer, are not included in the reports. This data is mapped to a separate category: Forms & Form responses.
Patient Finder pseudonymizes data in all texts, e.g. names, social security numbers, addresses, and telephone numbers. Measurements (e.g. Ejection Fraction), lab values (e.g. LDL values) and medical concepts (such as myocardial infarction) are also extracted from reports, if NLP is available for the language used at the hospital.
In some EHRs certain reports are not captured in full free texts form, but are recorded in a semi-structured way in a standard form/questionnaire. Examples of these we've seen in NL and BE EHR systems are referral letters, partus reports or consultation notes. These data are then not mapped to reports but will be made available in the Form & Form Responses nested categories.
Overview
| Filter name in app | Priority | FHIR field (PFS) | Brief description | Example data |
|---|---|---|---|---|
| ID | Must have | DiagnosticReport.identifier.value | Unique identifier for report. | |
| Report type | Must have | DiagnosticReport.category.coding.display | The kind of report you will be searching through. | Radiology report, surgery report, discharge letter, consulation notes, outpatient clinic report, pathology report. |
| Content | Must have | DiagnosticReport.presentedForm.data or DiagnosticReport.conclusion | The textual, free text content of the report. | Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. |
| Age at time of event | Must have | Derived from Patient (DiagnosticReport.subject) | Age of the patient, in years, when the report was created. | |
| Status | Could have | DiagnosticReport.status | The status of the report or the report content. | Concept, approved, to correct. |
| Specialism | Should have | Not yet mapped | Specialsm that filed the report. | Gastroenterology, endocrinology, oncology |
| Care provider name | Could have | Derived from Practitioner (DiagnosticReport.performer) | Name of the care provider that created the report. | Dr. Jane Doe, nurse John Doe. |
| Care provider position | Should have | Derived from Practitioner (DiagnosticReport.performer) | Position of the care provider that created the report. | Neurologist, dietician, doctor-in-training. |
| Attachment ID | Could have | DiagnosticReport.media.link | ID of attachments linked to the content of the report, eg. images obtained during echography. The report will describe what is seen on the images and the conclusions drawn from this. | BL10029 |
| Report date | Must have | DiagnosticReport.effective[x].effectiveDateTime or DiagnosticReport.effective[x].effectivePeriod.start | Date on which the report was last saved. | DD-MM-YYYY hh:mm |