DiagnosticReport
ClinicalThe 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.
| Path | Card. | Type | Description & Constraints |
|---|---|---|---|
| DiagnosticReport | 0..* | — | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
| .idΣ | 0..1 | String | Logical id of this artifact |
| .metaΣ | 0..1 | Meta | Metadata about the resource |
| .implicitRules?!Σ | 0..1 | uri | A set of rules under which this content was created |
| .language | 0..1 | code | Language of the resource content Bindinglanguages(preferred) |
| .text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| .contained | 0..* | Resource | Contained, inline Resources |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?! | 0..* | Extension | Extensions that cannot be ignored |
| .identifierΣ | 0..* | Identifier | Business identifier for report |
| .basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| .status?!Σ | 1..1 | code | registered | partial | preliminary | final + Bindingdiagnostic-report-status(required) |
| .categoryΣ | 0..* | CodeableConcept | Service category Bindingdiagnostic-service-sections(example) |
| .codeΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Bindingreport-codes(preferred) |
| .subjectΣ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| .encounterΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
| .effective[x]Σ | 0..1 | dateTime | Period | Clinically relevant time/time-period for report |
| .issuedΣ | 0..1 | instant | DateTime this version was made |
| .performerΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| .resultsInterpreterΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| .specimen | 0..* | Reference(Specimen) | Specimens this report is based on |
| .result | 0..* | Reference(Observation) | Observations |
| .imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| .mediaΣ | 0..* | BackboneElement | Key images associated with this report |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .comment | 0..1 | string | Comment about the image (e.g. explanation) |
| .linkΣ | 1..1 | Reference(Media) | Reference to the image source |
| .conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results |
| .conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Bindingclinical-findings(example) |
| .presentedForm | 0..* | Attachment | Entire report as issued |