ID

40050

Descrição

This is a complete version of the FHIR resource DiagnosticReport v4.0.0. FHIR version R4 (v4.0.0). FHIR is a platform specification that defines a set of capabilities use across the healthcare process, in all jurisdictions, and in lots of different context. https://www.hl7.org/fhir/resourcelist.html 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.

Link

https://www.hl7.org/fhir/resourcelist.html

Palavras-chave

Versões (2)
  1. 10/03/2020 10/03/2020 -
  2. 12/03/2020 12/03/2020 -
Titular dos direitos

HL7FHIR

Transferido a

10 de março de 2020

DOI

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Licença

Creative Commons BY-NC 4.0
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FHIR v4.0.0

Inglês

ODM-Form

1 Formulários  
  1. StudyEvent: ODM
    1. ODM-Form
Diagnostic Report
Descrição

Diagnostic Report

Alias
UMLS CUI-1
C1978267
Diagnostic report identifier
Descrição

Identifiers assigned to this report by the performer or other systems.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0600091
Details concerning a service requested
Descrição

DiagnosticReport.basedOn

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1527178
Status of the diagnostic report
Descrição

The status of the diagnostic report. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-diagnostic-report-status.html

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0449438
Category of the diagnostic report
Descrição

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. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-diagnostic-report-status.html

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0683312
Code/name of the diagnostic report
Descrição

A code or name that describes this diagnostic report. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-report-codes.html

Tipo de dados

integer

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0805701
UMLS CUI [1,3]
C0027365
Subject of the diagnostic report
Descrição

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.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1550501
Encounter which the diagnostic report is about
Descrição

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

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1947978
Time or time-period the observed values are related to
Descrição

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.

Tipo de dados

datetime

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1948053
Date and time the report was made available to providers
Descrição

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

Tipo de dados

datetime

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1272689
UMLS CUI [1,3]
C1264639
Performer of the report
Descrição

The diagnostic service that is responsible for issuing the report.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1550480
Interpreter of report's results
Descrição

The practitioner or organization that is responsible for the report's conclusions and interpretations.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0150646
UMLS CUI [1,3]
C1274040
Specimen the report is about
Descrição

Details about the specimens on which this diagnostic report is based.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0370003
Results of the diagnostic report
Descrição

Observations that are part of this diagnostic report.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1274040
Details of any imaging performed during the diagnostic investigation
Descrição

One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0011923
Conclusion of the diagnostic report
Descrição

Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1707478
Code that represents the conclusion of the diagnostic report
Descrição

One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-clinical-findings.html

Tipo de dados

integer

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C1707478
UMLS CUI [1,3]
C0805701
Text representation of the entire result
Descrição

Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0681492
Diagnostic report media
Descrição

Diagnostic report media

Alias
UMLS CUI-1
C1978267
UMLS CUI-2
C0011923
A list of key images associated with this report
Descrição

A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0011923
UMLS CUI [1,3]
C1706198
UMLS CUI [1,4]
C0745732
Comment about the image
Descrição

A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0011923
UMLS CUI [1,3]
C0947611
Reference to the image source.
Descrição

DiagnosticReport.media.link

Tipo de dados

text

Alias
UMLS CUI [1,1]
C1978267
UMLS CUI [1,2]
C0011923
UMLS CUI [1,3]
C1514812
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Similar models

ODM-Form

1 Formulários
  1. StudyEvent: ODM
    1. ODM-Form
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Diagnostic Report
C1978267 (UMLS CUI-1)
DiagnosticReport.identifier
Item
Diagnostic report identifier
text
C1978267 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
DiagnosticReport.basedOn
Item
Details concerning a service requested
text
C1978267 (UMLS CUI [1,1])
C1527178 (UMLS CUI [1,2])
Item
Status of the diagnostic report
text
C1978267 (UMLS CUI [1,1])
C0449438 (UMLS CUI [1,2])
DiagnosticReport.status
Code List
Status of the diagnostic report
CL Item
Registered  (registered)
The existence of the report is registered, but there is nothing yet available. (Comment:en)
CL Item
Partial  (partial)
This is a partial (e.g. initial, interim or preliminary) report: data in the report may be incomplete or unverified. (Comment:en)
CL Item
Preliminary  (preliminary)
Verified early results are available, but not all results are final. (Comment:en)
CL Item
Final (final)
The report is complete and verified by an authorized person. (Comment:en)
CL Item
Amended (amended)
Subsequent to being final, the report has been modified. This includes any change in the results, diagnosis, narrative text, or other content of a report that has been issued. (Comment:en)
CL Item
Corrected (corrected)
Subsequent to being final, the report has been modified to correct an error in the report or referenced results. (Comment:en)
CL Item
Appended  (appended)
Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. (Comment:en)
CL Item
Cancelled  (cancelled)
The report is unavailable because the measurement was not started or not completed (also sometimes called "aborted"). (Comment:en)
CL Item
Entered in Error (entered-in-error)
The report has been withdrawn following a previous final release. This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".). (Comment:en)
CL Item
Unknown  (unknown)
The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which. (Comment:en)
Item
Category of the diagnostic report
text
C1978267 (UMLS CUI [1,1])
C0683312 (UMLS CUI [1,2])
DiagnosticReport.status
Code List
Category of the diagnostic report
CL Item
Audiology  (AU)
CL Item
Blood Gases  (BG)
CL Item
Blood Bank  (BLB)
CL Item
Cytogenetics  (CG)
CL Item
Chemistry  (CH)
CL Item
Cytopathology  (CP)
CL Item
CAT Scan  (CT)
CL Item
Cardiac Catheterization  (CTH)
CL Item
Cardiac Ultrasound  (CUS)
CL Item
Electrocardiac (e.g., EKG, EEC, Holter)  (EC)
CL Item
Electroneuro (EEG, EMG,EP,PSG)  (EN)
CL Item
Genetics  (GE)
CL Item
Hematology  (HM)
CL Item
Bedside ICU Monitoring  (ICU)
CL Item
Immunology  (IMM)
CL Item
Laboratory  (LAB)
CL Item
Microbiology  (MB)
CL Item
Mycobacteriology  (MCB)
CL Item
Mycology  (MYC)
CL Item
Nuclear Magnetic Resonance  (NMR)
CL Item
Nuclear Medicine Scan  (NMS)
CL Item
Nursing Service Measures  (NRS)
CL Item
Outside Lab  (OSL)
CL Item
Occupational Therapy  (OT)
CL Item
Other  (OTH)
CL Item
OB Ultrasound  (OUS)
CL Item
Pulmonary Function  (PF)
CL Item
Pharmacy  (PHR)
CL Item
Physician (Hx. Dx, admission note, etc.)  (PHY)
CL Item
Physical Therapy  (PT)
CL Item
Radiology  (RAD)
CL Item
Respiratory Care (therapy)  (RC)
CL Item
Radiation Therapy  (RT)
CL Item
Radiology Ultrasound  (RUS)
CL Item
Radiograph  (RX)
CL Item
Surgical Pathology  (SP)
CL Item
Serology  (SR)
CL Item
Toxicology  (TX)
CL Item
Virology  (VR)
CL Item
Vascular Ultrasound  (VUS)
CL Item
Cineradiograph (XRC)
Item
Code/name of the diagnostic report
integer
C1978267 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
C0027365 (UMLS CUI [1,3])
DiagnosticReport.status
Code List
Code/name of the diagnostic report
DiagnosticReport.subject
Item
Subject of the diagnostic report
text
C1978267 (UMLS CUI [1,1])
C1550501 (UMLS CUI [1,2])
DiagnosticReport.encounter
Item
Encounter which the diagnostic report is about
text
C1978267 (UMLS CUI [1,1])
C1947978 (UMLS CUI [1,2])
DiagnosticReport.effective[x]
Item
Time or time-period the observed values are related to
datetime
C1978267 (UMLS CUI [1,1])
C1948053 (UMLS CUI [1,2])
DiagnosticReport.issued
Item
Date and time the report was made available to providers
datetime
C1978267 (UMLS CUI [1,1])
C1272689 (UMLS CUI [1,2])
C1264639 (UMLS CUI [1,3])
DiagnosticReport.performer
Item
Performer of the report
text
C1978267 (UMLS CUI [1,1])
C1550480 (UMLS CUI [1,2])
DiagnosticReport.resultsInterpreter
Item
Interpreter of report's results
text
C1978267 (UMLS CUI [1,1])
C0150646 (UMLS CUI [1,2])
C1274040 (UMLS CUI [1,3])
DiagnosticReport.specimen
Item
Specimen the report is about
text
C1978267 (UMLS CUI [1,1])
C0370003 (UMLS CUI [1,2])
DiagnosticReport.result
Item
Results of the diagnostic report
text
C1978267 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
DiagnosticReport.imagingStudy
Item
Details of any imaging performed during the diagnostic investigation
text
C1978267 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
DiagnosticReport.conclusion
Item
Conclusion of the diagnostic report
text
C1978267 (UMLS CUI [1,1])
C1707478 (UMLS CUI [1,2])
DiagnosticReport.conclusionCode
Item
Code that represents the conclusion of the diagnostic report
integer
C1978267 (UMLS CUI [1,1])
C1707478 (UMLS CUI [1,2])
C0805701 (UMLS CUI [1,3])
DiagnosticReport.presentedForm
Item
Text representation of the entire result
text
C1978267 (UMLS CUI [1,1])
C0681492 (UMLS CUI [1,2])
Item Group
Diagnostic report media
C1978267 (UMLS CUI-1)
C0011923 (UMLS CUI-2)
DiagnosticReport.media
Item
A list of key images associated with this report
text
C1978267 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
C1706198 (UMLS CUI [1,3])
C0745732 (UMLS CUI [1,4])
DiagnosticReport.media.comment
Item
Comment about the image
text
C1978267 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,3])
DiagnosticReport.media.link
Item
Reference to the image source.
text
C1978267 (UMLS CUI [1,1])
C0011923 (UMLS CUI [1,2])
C1514812 (UMLS CUI [1,3])
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