DiagnosticReport

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The 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.

 

Response Description

Sample Response

{

  "resourceType": "DiagnosticReport",

  "id": "DEV-DEV-11913-3270",

  "meta": {

     "lastUpdated": "2022-10-19T09:32:56-04:00",

     "profile": [

        "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note"

     ]

  },

  "text": {

     "status": "generated",

     "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><td>Patient:</td><td>Cole Andersonian, Sr. (DEV-DEV-11913)          </td></tr><tr><td>Order#:</td><td>101950473949</td></tr><tr><td>Ordered On:</td><td>10/01/2022 14:01:00.000+02:00</td></tr><tr><td>Ordered By:</td><td>Steven Aspen, M. D.</td></tr></tbody></table><p></p><p></p><table border=1><tbody><tr><th colspan=2>Test</th><th>Code</th></tr><tr><td colspan=2>XRAY, Chest 3 views</td><td>71020</td></tr><tr><td colspan=2>XRAY, Chest 1 View Pa</td><td>71010</td></tr></tbody></table></div>"

  },

  "status": "final",

  "category": [

     {

        "coding": [

           {

              "system": "http://loinc.org",

              "code": "LP29684-5",

              "display": "Radiology"

           },

           {

              "system": "http://terminology.hl7.org/CodeSystem/v2-0074",

              "code": "RAD",

              "display": "Radiology"

           }

        ]

     }

  ],

  "code": {

     "coding": [

        {

           "system": "http://www.ama-assn.org/go/cpt",

           "code": "71020",

           "display": "XRAY, Chest 3 views"

        },

        {

           "system": "http://www.ama-assn.org/go/cpt",

           "code": "71010",

           "display": "XRAY, Chest 1 View Pa"

        }

     ],

     "text": "This test is scheduled for 10/19/22 at 10:00 am\nComment relating specifically to XRAY, Chest 3 views, Comment relating specifically to XRAY, Chest 1 View Pa"

  },

  "effectiveDateTime": "2022-10-17T12:00:00-04:00",

  "issued": "2022-10-17T12:00:00-04:00",

  "subject": {

     "reference": "Patient/DEV-DEV-11913",

     "display": "Cole Andersonian, Sr. (DEV-DEV-11913)"

  },

  "encounter": {

     "reference": "Encounter/DEV-DEV-11913-0014792",

     "display": "10/25/2022 at 7:00 am, Blood Pressure Visit with provider 117 at location OF1"

  },

  "performer": [

     {

        "reference": "Organization/DEV--RADNET",

        "display": "Radnet"

     }

  ],

  "result": [

     {

        "reference": "Observation/DEV-DEV-11913-L6478",

        "display": "XRAY, Chest 3 views"

     },

     {

        "reference": "Observation/DEV-DEV-11913-L6479",

        "display": "XRAY, Chest 1 View Pa"

     }

  ],

  "presentedForm": [

     {

        "contentType": "application/msword",

        "data": "{base64-encoded data}"

     }

  ]

}

 

DiagnosticReport.id

 

The logical ID of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality

0..1

Type

string

Comment

The only time that a resource does not have an ID is when it is being submitted to the server using a create operation.

 

 

DiagnosticReport.meta

 

Metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Cardinality

0..1

Type

Meta

 

 

DiagnosticReport.status

 

The status of the diagnostic report.

Cardinality

1..1

Type

code: SHALL be taken from DiagnosticReportStatus

Requirements

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

 

 

DiagnosticReport.category:LaboratorySlice

 

A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

Cardinality

1..1

Type

CodeableConcept DiagnosticServiceSectionCodes

Comment

<valueCodeableConcept xmlns="http://hl7.org/fhir">

 <coding>

   <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>

   <code value="LAB"/>

 </coding>

</valueCodeableConcept>

 

 

DiagnosticReport.category

 

A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

Cardinality

1..*

Type

CodeableConcept DiagnosticServiceSectionCodes

Comment

Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.

 

 

DiagnosticReport.category.coding.system

 

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality

0..1

Type

uri

Requirements

Need to be unambiguous about the source of the definition of the symbol.

 

 

DiagnosticReport.category.coding.code

 

A symbol in syntax defined by the system.

Cardinality

0..1

Type

code

Comment

Most likely LAB for laboratory results

 

 

DiagnosticReport.category.coding.display

 

Plain text narrative that identifies the code in the system.

Cardinality

0..1

Type

string

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

 

 

DiagnosticReport.code

 

The test, panel or battery that was ordered.

Cardinality

1..1

Type

CodeableConcept SHALL be taken from US Core Diagnostic Report Laboratory Codes; other codes may be used where these codes are not suitable LOINC codes

Comment

UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists.

 

 

DiagnosticReport.effectiveDateTime

 

The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.

Cardinality

0..1

Type

dateTime

Comment

If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.

Requirements

Need to know where in the patient history to file/present this report.

 

 

DiagnosticReport.issued

 

The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.

Cardinality

0..1

Type

instant

Comment

May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

Requirements

Clinicians need to be able to check the date that the report was released.

 

 

DiagnosticReport.subject

 

The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.

Cardinality

1..1

Type

Reference(USCorePatientProfile)

Requirements

SHALL know the subject context.

 

 

DiagnosticReport.encounter

 

The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.

 

Cardinality

0..1

Type

Reference(Encounter)

Requirements

Links the request to the Encounter context.

 

 

DiagnosticReport.performer

 

The diagnostic service that is responsible for issuing the report.

Cardinality

0..*

Type

Reference(USCorePractitionerProfile | USCoreOrganizationProfile | USCoreCareTeam | USCorePractitionerRoleProfile)

Comment

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

 

 

DiagnosticReport.result

 

Observations that are part of this diagnostic report.

Cardinality

0..*

Type

Reference(USCoreLaboratoryResultObservationProfile)

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

 


 

Search

 

URL Syntax

Two HTTP methods are supported for searching: GET and POST. It is recommended to use HTTP POST.

Visit the FHIR Sandbox to try requests.

 

 

HTTP GET - searching

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?{query string}

 

HTTP GET - return single record

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport/{resource id}

 

HTTP POST - searching

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport/_search

Set the Content-Type header to application/x-www-urlencoded

The body of the request is a similar query string used in the GET type of request detailed above.

 

 

Error Handling

If no records are returned or invalid search parameters are provided, then an HTTP 400 Bad Request is returned.

The body of the response will be an OperationOutcome.

 

 

Supported Search Parameters

 

_id

Corresponds to

DiagnosticReport.id

Search

exact

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs

 

Returns all Reports for patient baddocs in practice dev.

 

patient

Corresponds to

DiagnosticReport.subject

Search

exact

Required

true

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs

 

Returns all Reports for patient baddocs in practice dev.

 

category

Corresponds to

DiagnosticReport.category.subject

Search

exact

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs&category=lab

 

Returns all lab Reports for patient baddocs in practice dev.

 

date

Corresponds to

DiagnosticReport.effectiveDateTime

Search

exact using the format of yyyy-MM-dd

Modifiers

ge - greater than or equal to

gt - greater than

le - less than or equal to

lt - less than

eq - equal to

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs&date=2020-10-20

 

Returns the Report for patient baddocs with the date of 10/20/2020.

 

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=20DEV-DEV-baddocs&date=ge2011-01-01&date=le2012-12-31&category=LAB

 

 

Returns all lab Reports for patient baddocs within the date range between 01/01/2011 and 12/31/2012.

 

category

Corresponds to

DiagnosticReport.category

Search

exact using the format of yyyy-MM-dd

Modifiers

ge - greater than or equal to

gt - greater than

le - less than or equal to

lt - less than

eq - equal to

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=20DEV-DEV-baddocs&date=ge2011-01-01&date=le2012-12-31&category=LAB

 

 

Returns all lab Reports for patient baddocs within the date range between 01/01/2011 and 12/31/2012.

 

status

Corresponds to

DiagnosticReport.status

Search

exact

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs&status=complete

 

Returns the Reports with complete status for patient baddocs.

 

code

Corresponds to

DiagnosticReport.code

Search

exact

Example

https://sandbox.pai.healthcare/preview/fhir/DiagnosticReport?patient=DEV-DEV-baddocs&code=30341-2,22314-9

 

Returns the Reports with codes 30341-2 and 22314-9 for patient baddocs.