Argonaut Clinical Notes Implementation Guide (Release 1.0.0 )

This page is part of the Argonaut Clinical Notes Implementation Guide (v1.0.0: Release) based on FHIR R3. This is the current published version. For a full list of available versions, see the Directory of published versions

StructureDefinition-argo-diagnosticreport-notes-and-reports

This profile sets minimum expectations for searching and fetching Diagnostic Reports and Notes using the DiagnosticReport resource. It is built independent of the US Core DiagnosticReport lab profile for initial testing. When US Core is balloted for R4 it may be merged into the existing profile. This profile identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the DiagnosticReport when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Argonaut Diagnostic Report profile:

  • Query for a specific Radiology note (e.g. 84178-3 Interventional Radiology Note)
  • Query for category of reports (e.g. all Cardiology reports)
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Diagnostic Report must have:

  1. a status
  2. a category of the DiagnosticReport
  3. a code describing the type of report
  4. a patient
  5. date and time the report was created
  6. an author (actor) producing the report

In addition it should have (if available):

  1. the encounter the report occurred within
  2. instant the report was released
  3. an image
  4. a referene to the full report (presentedForm)

Profile specific implementation guidance:

Servers must support the DiagnosticReport.category element and SHOULD support at a minimum the 3 concepts of Cardiology, Radiology, and Pathology. Servers are encouraged to support additional categories.

When Clients search with DiagnosticReport.category element across different FHIR servers they may find inconsistent results. Servers that participated in the development of this guide allow their customers to categorize reports to their end-user requirements which vary. A customer may categorize an orthopedic note with the category. Encouraging support for this element will help identify inconsistencies.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://fhir.org/guides/argonaut/clinicalnotes/StructureDefinition/argo-diagnosticreport-notes-and-reports

Published on Tue Apr 10 23:48:14 AEST 2018 as a active by .

This profile builds on DiagnosticReport

Summary

Mandatory: 5 elements (1 nested mandatory element)
Must-Support: 11 elements

Structures

This structure refers to these other structures:

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*Argonaut Diagnostic Report Profile for Imaging
... status SI1..1codeBinding: DiagnosticReportStatus (required)
DiagnosticReport-1: When DiagnosticReport.status is final/amended/corrected/appended, the presentedForm, conclusion or codedDiagnosis must be present
... category S1..1CodeableConceptBinding: Argonaut DiagnosticReport Category Value Set (extensible)
... code S1..1CodeableConceptUS Core Report Code
Binding: LOINC Diagnostic Report Codes (extensible)
... subject S1..1Reference(US Core Patient Profile)
... context S0..1Reference(US Core Encounter Profile)
... effective[x] S1..1dateTime, PeriodTime of the report or note
... issued S0..1instant
... performer S0..*BackboneElement
.... actor S1..1Reference(US Core Practitioner | US Core Organization Profile)
... image S0..*BackboneElement
... presentedForm S0..*Attachment

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*Argonaut Diagnostic Report Profile for Imaging
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest)What was requested
... status ?!SΣI1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
DiagnosticReport-1: When DiagnosticReport.status is final/amended/corrected/appended, the presentedForm, conclusion or codedDiagnosis must be present
... category SΣ1..1CodeableConceptService category
Binding: Argonaut DiagnosticReport Category Value Set (extensible)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: LOINC Diagnostic Report Codes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... context SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodTime of the report or note
... issued SΣ0..1instantDateTime this version was released
... performer SΣI0..*BackboneElementParticipants in producing the report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... role Σ0..1CodeableConceptType of performer
Binding: Procedure Performer Role Codes (example)
.... actor SΣ1..1Reference(US Core Practitioner | US Core Organization Profile)Practitioner or Organization participant
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(Observation)Observations - simple, or complex nested groups
... imagingStudy 0..*Reference(ImagingStudy | ImagingManifest)Reference to full details of imaging associated with the diagnostic report
... image SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis 0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (example)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Summary

Mandatory: 5 elements (1 nested mandatory element)
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*Argonaut Diagnostic Report Profile for Imaging
... status SI1..1codeBinding: DiagnosticReportStatus (required)
DiagnosticReport-1: When DiagnosticReport.status is final/amended/corrected/appended, the presentedForm, conclusion or codedDiagnosis must be present
... category S1..1CodeableConceptBinding: Argonaut DiagnosticReport Category Value Set (extensible)
... code S1..1CodeableConceptUS Core Report Code
Binding: LOINC Diagnostic Report Codes (extensible)
... subject S1..1Reference(US Core Patient Profile)
... context S0..1Reference(US Core Encounter Profile)
... effective[x] S1..1dateTime, PeriodTime of the report or note
... issued S0..1instant
... performer S0..*BackboneElement
.... actor S1..1Reference(US Core Practitioner | US Core Organization Profile)
... image S0..*BackboneElement
... presentedForm S0..*Attachment

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*Argonaut Diagnostic Report Profile for Imaging
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest)What was requested
... status ?!SΣI1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
DiagnosticReport-1: When DiagnosticReport.status is final/amended/corrected/appended, the presentedForm, conclusion or codedDiagnosis must be present
... category SΣ1..1CodeableConceptService category
Binding: Argonaut DiagnosticReport Category Value Set (extensible)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: LOINC Diagnostic Report Codes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... context SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodTime of the report or note
... issued SΣ0..1instantDateTime this version was released
... performer SΣI0..*BackboneElementParticipants in producing the report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... role Σ0..1CodeableConceptType of performer
Binding: Procedure Performer Role Codes (example)
.... actor SΣ1..1Reference(US Core Practitioner | US Core Organization Profile)Practitioner or Organization participant
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(Observation)Observations - simple, or complex nested groups
... imagingStudy 0..*Reference(ImagingStudy | ImagingManifest)Reference to full details of imaging associated with the diagnostic report
... image SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis 0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (example)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

GET [base]/DiagnosticReport?patient=[id]&code=[LOINC{,LOINC2,LOINC3,...}]

Example: GET [base]/DiagnosticReport?patient=1032702&code=84178-3 (LOINC = 84178-3 Interventional Radiology Note)

Support: Mandatory support search by a specific DiagnosticReport code. SHOULD support search by multiple report codes.

Implementation Notes: Search based on DiagnosticReport code(s). This fetches a bundle of all DiagnosticReport resources for a specific diagnostic order code(s) for the specified patient (how to search by reference) and (how to search by token).

GET [base]/DiagnosticReport?patient=[id]&category=[system]|[code]

Example: GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5

Support: Recommend support search by patient and category codes specified in Argonaut DiagnosticReport Category Codes.

Implementation Notes: Search based on diagnostic report category code, for example Radiology (LP29684-5). This fetches a bundle of all LP29684-5 related DiagnosticReport resources for the specified patient (how to search by reference) and (how to search by token).

GET [base]/DiagnosticReport?patient=[id]&category=[system]|[code]&date=[date]{&date=[date]}

Example: GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5&date=ge2010-01-14

Support: Recommend support search by category codes in Argonaut DiagnosticReport Category Codes and date or period.

Implementation Notes: Search based on category code, for example Radiology (LP29684-5), and date. This fetches a bundle of all DiagnosticReport resources with category LP29684-5 for the specified patient for a specified time period (how to search by reference), (how to search by token) and (how to search by date).