DiagnosticReport

A diagnostic report is the set of information typically provided by a diagnostic service when investigations are complete. The information includes a mix of atomic results, text reports, images, and codes. The mix varies depending on the nature of the diagnostic procedure, and sometimes on the nature of the outcomes for a particular investigation.

The DiagnosticReport resource includes findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or the specimens derived from these. The report includes clinical context (e.g., requesting and provider information) and some mix of atomic results, images, textual and coded interpretations, and formatted representations of diagnostic reports. Laboratory reports, pathology reports, and imaging reports should be represented using the DiagnosticReport resource.

The DiagnosticReport resource is suitable for the following types of diagnostic reports:

• Laboratory (Clinical Chemistry, Hematology, Microbiology, etc.)
• Pathology, Histopathology, and related disciplines
• Imaging Investigations (x-ray, CT, MRI, etc.)
• Other diagnostics (Cardiology, Gastroenterology, etc.)

The DiagnosticReport resource inbcludes information about the diagnostic report itself, as well as information about the subject and, in the case of laboratory tests, the specimen of the report.

Note: The DiagnosticReport resource is not intended to support cumulative result presentation. The resource does not yet provide full support for detailed structured reports of sequencing; this is planned for a future release.

The DiagnosticReport resource uses one particular set of terms when describing the various parts of a diagnostic report.

• A practitioner requests a set of tests.
• The diagnostic service returns a report which may contain a narrative (a written summary of the outcomes, and/or results) of the individual pieces of atomic data, each of which are observations.
• The results are assembled in groups which are nested structures of Observation resources. Traditionally, these are referred to as panels or batteries by laboratories and can be used to represent relationships between the individual data items.

Typically, a report is either all data, no narrative (e.g., Core lab); a mix of data with some concluding narrative (e.g., Structured Pathology Report, Bone Density); or all narrative (e.g., a typical imaging report, histopathology). The DiagnosticReport resource provides for these 3 different presentations:

• As atomic data items — a hierarchical set of nested references to Observation resources often including pathologist/radiologist interpretations, one or more image, possibly with a conclusion, and/or one or more coded diagnoses. The conclusion and the coded diagnoses are part of the atomic data and should be duplicated in the narrative and the presented form, if the latter is present.
• As narrative — an XHTML presentation in the standard resource narrative.
• As a presented form — a rich-text representation of the report, typically a PDF.

Related Resources

The DiagnosticReport resource is referenced by these resources:

C	D-M	M-S
CarePlan	DeviceRequest	MedicationStatement
ChargeItem	DeviceUseStatement	Procedure
ClinicalImpression	FamilyMemberHistory	RequestGroup
Communication	GuidanceResponse	RiskAssessment
CommunicationRequest	ImagingStudy	ServiceRequest
Condition	Immunization	SupplyRequest
Contract	MedicationAdministration

Where there are details of interest about how the diagnostic procedure was performed, the Procedure resource is used to describe the activity.

The Observation resource is referenced by the DiagnosticReport to provide the atomic results for a particular investigation.

For a more narrative driven report with less workflow (e.g., histology/mortuary, etc.), using the Composition resource is more appropriate.

Image and media representations of the report and its supporting images are referenced in the DiagnosticReport resource. The details for and actual image instances can be referenced directly in the Diagnostic report using the imaging element, or by indirect reference through ImagingStudy resources.

Note: ImagingStudy and ImageObjectStudy and the media element are somewhat overlapping. Usually, the list of image references in the image element will also be found in one of the imaging study resources.

US Core

The following links define the Value Set and various Search Parameters for the US Core DiagnosticReport:

• US Core DiagnosticReport (3.8.1) resource profile.
• US Core Detailed Descriptions for the elements in the DiagnosticReport (3.8.0.1) resource profile
• US Core ValueSet — DiagnosticReport Report and Note Codes Expansion (5.20.0.1)
• US Core DiagnosticReportCode SearchParameter (6.4.1)
• US Core DiagnosticReportDate SearchParameter (6.14.1)
• US Core DiagnosticReportStatus SearchParameter (6.31.1)
• US Core DiagnosticReportCategory SearchParameter (6.33.1)
• US Core CoreDiagnosticReportPatient SearchParameter (6.33.1)

Mandatory Search Parameters

The following search parameters and search parameter combinations should be supported.

For a list of optional search parameters, see StructureDefinition-us-core-diagnosticreport-note

For More Information

• FHIR R4 DiagnosticReport (10.3) resource.
• Detailed Descriptions (10.3.8) for the elements in the DiagnosticReport resource
• Terminology Bindings (10.3.4.1) for the DiagnosticReport resource
• Search Parameters (10.3.6) for the DiagnosticReport resource
• Search Notes (10.3.5) for the DiagnosticReport resource