DiagnosisReport - FHIR
- Rodolfo Melia
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FHIR resource link | https://build.fhir.org/diagnosticreport.html |
FHIR definition (v5.0) | The findings and interpretation of diagnostic tests performed on patients, groups of patients, products, substances, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. The report also includes non-clinical context such as batch analysis and stability reporting of products and substances. |
PSI use case | Findings and interpretation of diagnostic tests performed on patients, groups of patients. The report includes context such a
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FHIR required properties | see below |
PSI required properties* | Country and PsiProjectCode * +text |
Extensions | future use |
Sample payload (minimum set) | {
"resourceType": "DiagnosticReport",
"id": "diagnosticreport-example",
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "16581-5",
"display": "HIV 1+2 Ab [Presence] in Serum"
}
],
"text": "HIV 1+2 Ab [Presence] in Serum"
},
"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "2013-01-17T08:00:00+00:00",
"issued": "2013-01-20T08:00:00+00:00",
"performer": [
{
"reference": "Practitioner/example"
}
],
"resultsInterpreter": [
{
"reference": "#p1"
}
],
"specimen": [
{
"reference": "#s1"
}
],
"result": [
{
"reference": "#r1"
}
],
...
} |
Notes for Diagnosis Report FHIR resource, per property
Property | Required by PSI? | Notes |
|---|---|---|
PSI tags | Yes [psi/fhir] | PENDING: implementation as extension |
optional [psi/fhir] | Service Request (could be a voucher) | |
status | Yes [psi/fhir] | for R4B: only for R5: |
category | Yes [psi] | Service category. Examples: |
code | Yes [psi/fhir] | LOINC code. Example: "http://loinc.org",
"code": "16581-5",
"display": "HIV 1+2 Ab [Presence] in Serum"List of LOINC codes for HIV Testing 75622-1 |
subject | Yes [psi] | The patient ID that this result relates to. |
encounter | optional [psi] | The encounter ID that triggered this diagnosis |
Yes [psi] | Who did the test | |
Yes [psi] | Who interpreted the results | |
specimen | optional [psi/fhir] | Sample ID, if applicable |
result | Yes [psi] | Although optional in FHIR, at PSI if we create a Diagnosis Report is because we have a result to store. Based on SNOMED CT Clinical findings. Examples need verification
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note | optional recommended [psi/fhir] | Comments about the diagnostic report |
media/link | optional [psi/fhir] | |
conclusion | optional [psi/fhir] | markdown, free text |
conclusionCode | optional [psi/fhir] | SNOMED CT code, if result is conclusive |