National Pathology FHIR Message Profile - Test Report
Test Report Overview for a Haematology or Chemical Pathology Test
Contains data on the report of tests performed on the patient and is populated with data from the performing organisation. The report may be a document, structured data or a combination of both. For unstructured reports there may or may not be additional structured data depending on what the GP practice decides should be coded into the clinical record. Each test report may contain multiple test batteries, test results and specimens.
Mapping for Diagnostic Report
How to populate the Diagnostic Report instance to conform to the profiles below:
| Level 1 | DiagnosticReport Resource | Level 2 | CareConnect-DiagnosticReport-1 | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Business Conformance | Type | Description, Constraints and Mapping for National Pathology Implementation | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource |
|||||||||
| - id | 0..1 | Optional | Id | Logical id of this artifact Must contain a UUID to identify the instance of a diagnosticReport |
|||||||
| - meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-DiagnosticReport-1' |
|||||||
| - identifier | 0..* | Mandatory | Identifier | Business identifier for report A business level identifier for the test report. Produced by the performing organisation. |
|||||||
| - - system | 1..1 | Mandatory | Uri | The namespace for the identifier value MUST contain the value 'https://tools.ietf.org/html/rfc4122'. |
|||||||
| - - value | 1..1 | Mandatory | String | The value that is unique MUST contain a UUID |
|||||||
| - basedOn | 0..* | Required | Reference | What was requested Constraint (ref-1): SHALL have a contained resource if a local reference is provided Reference to the Test Request Summary. |
|||||||
| Required | CareConnect-ProcedureRequest-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-ProcedueRequest-1' | |||||||||
| - status | 1..1 | Mandatory | Code | registered : partial : preliminary : final + Binding (required): The status of the diagnostic report as a whole. Diagnostic-Report-Status The status of the Test Report. MUST be set to 'partial' when the report is issued on an initial, interim or preliminary basis, for example because some of the requested tests have not yet completed. MUST be set to ‘final’ when the report is completed. MUST be set to ‘unknown’ when the status is unable to be determined. |
|||||||
| - category | 0..1 | Optional | CodeableConcept | Service category Binding (preferred): Codes for diagnostic service sections. ( http://hl7.org/fhir/stu3/valueset-diagnostic-service-sections.html ) |
|||||||
| - - coding | 0..* | Optional | Coding | Code defined by a terminology system Slicing: Discriminator: system, Ordering: false, Rules: Open |
|||||||
| - code | 1..1 | Mandatory | CodeableConcept | Name/Code for this diagnostic report Binding (preferred): Codes that describe Diagnostic Reports. [Report Codes]( https://fhir.hl7.org.uk/STU3/ValueSet/CareConnect-ReportCodeSnCT-1 ) A SNOMED CT coded name of the name of the test report. |
|||||||
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
|||||||
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system | |||||||
| - - - display | 1..1 | Mandatory | String | Representation defined by the system | |||||||
| - - text | 0..1 | Optional | String | Plain text representation of the concept Where a SNOMED code does not meet the report name requirements a text alternative may be used |
|||||||
| - subject | 1..1 | Mandatory | Reference | The subject of the report - usually, but not always, the patient Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
|||||||
| Mandatory | CareConnect-Patient-1 | This MUST be to the Patient resource profiled as CareConnect-Patient-1 | |||||||||
| - issued | 1..1 | Mandatory | Instant | DateTime this version was released The date and time on which the test report was issued by the performer to the requester. | |||||||
| - performer | 0..* | Required | BackboneElement | Participants in producing the report Reference to the person and/or organisation that authored the test report. |
|||||||
| - - actor | 1..1 | Mandatory | Reference | Practitioner or Organization participant Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
|||||||
| 1..1 | Mandatory | CareConnect-Organization-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Organization-1 if a Practitioner is also recorded.' | ||||||||
| 1..1 | Mandatory | CareConnect-Practitioner-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Practitioner-1' | ||||||||
| - specimen | 0..* | Required | Reference | Specimens this report is based on Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
|||||||
| 0..* | Mandatory | CareConnect-Specimen-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Specimen-1' | ||||||||
| - result | 0..* | Required | Reference | Observations - simple, or complex nested groups Constraint (ref-1): SHALL have a contained resource if a local reference is provided Reference to the result(s) which are contained in the DiagnosticReport. This may contain references to standalone test results, test group headers (which then reference further results) or a mixture of both. |
|||||||
| 0..* | Mandatory | CareConnect-Observation-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Observation-1'. Reference to the result(s)/result groups contained in the report | ||||||||
| - conclusion | 0..1 | Required | String | Clinical Interpretation of test results Human readable clinical summary relating to the test report. It is provided by the performing HCP. |
|||||||
| - codedDiagnosis | 0..* | Required | CodeableConcept | Codes for the conclusion Binding (preferred): A SNOMED Coded finding for the test report. CareConnect-Finding-Code A coded finding of the test report. Produced by the organisation that performed the tests. |
|||||||
| - - coding | 0..* | Required | Coding | Code defined by a terminology system | |||||||
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
|||||||
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system | |||||||
| - - - display | 1..1 | Mandatory | String | Representation defined by the system |
Examples
Basic example of a Diagnostic Report
