FHIR Implementation Guide for ABDM CI Build v2.0.1
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This Implementation guide is published and maintained by NRCeS for NHA.
This version is based on the ABDM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-DiagnosticReportLab

Laboratory results are grouped and summarized using the DiagnosticReport resource which typically reference Observation resource(s). Each Observation resource represents an individual laboratory test and result value or component result values, or a “nested” panel (such as a microbial susceptibility panel) which references other observations. They can also be presented in report form or as free text. This profile sets minimum expectations for the DiagnosticReport resource to record, search, and fetch laboratory results associated with a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

The resources capturing the measurements, tests, panels, observations, interpretation, etc. in Diagnostics domain can use LOINC codes. The guide for using the LOINC codes in the FHIR resources can be found here.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportLab

This profile builds on DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S0..*Reference(CarePlan | ImmunizationRecommendation | NutritionOrder | MedicationRequest | ServiceRequest)What was requested
... status S1..1coderegistered | partial | preliminary | final +
... category S0..*CodeableConceptService category
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... code S1..1CodeableConceptName/Code for this diagnostic report
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... subject 0..1Reference(Group | Device | Location | Patient)The subject of the report - usually, but not always, the patient
... encounter 0..1Reference(Encounter)Health care event when test ordered
... performer S0..*Reference(CareTeam | Organization | Practitioner | PractitionerRole)Responsible Diagnostic Service
... resultsInterpreter S1..*Reference(CareTeam | Practitioner | Organization | PractitionerRole)Primary result interpreter
... specimen S0..*Reference(Specimen)Specimens this report is based on
... result S1..*Reference(Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media
.... link 1..1Reference(Media)Reference to the image source
... conclusion S1..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... presentedForm
.... contentType 1..1codeMime type of the content, with charset etc.
.... data 1..1base64BinaryData inline, base64ed

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical 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: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..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 S0..*Reference(CarePlan | ImmunizationRecommendation | NutritionOrder | MedicationRequest | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category SΣ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Group | Device | Location | Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(CareTeam | Organization | Practitioner | PractitionerRole)Responsible Diagnostic Service
... resultsInterpreter SΣ1..*Reference(CareTeam | Practitioner | Organization | PractitionerRole)Primary result interpreter
... specimen S0..*Reference(Specimen)Specimens this report is based on
... result S1..*Reference(Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion S1..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... presentedForm 0..*AttachmentEntire report as issued
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... contentType Σ1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
.... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.


Example General: en-AU
.... data 1..1base64BinaryData inline, base64ed
.... url Σ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
.... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
.... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
.... creation Σ0..1dateTimeDate attachment was first created

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S0..*Reference(CarePlan | ImmunizationRecommendation | NutritionOrder | MedicationRequest | ServiceRequest)What was requested
... status S1..1coderegistered | partial | preliminary | final +
... category S0..*CodeableConceptService category
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... code S1..1CodeableConceptName/Code for this diagnostic report
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... subject 0..1Reference(Group | Device | Location | Patient)The subject of the report - usually, but not always, the patient
... encounter 0..1Reference(Encounter)Health care event when test ordered
... performer S0..*Reference(CareTeam | Organization | Practitioner | PractitionerRole)Responsible Diagnostic Service
... resultsInterpreter S1..*Reference(CareTeam | Practitioner | Organization | PractitionerRole)Primary result interpreter
... specimen S0..*Reference(Specimen)Specimens this report is based on
... result S1..*Reference(Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media
.... link 1..1Reference(Media)Reference to the image source
... conclusion S1..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
.... coding S0..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... text S0..1stringPlain text representation of the concept
... presentedForm
.... contentType 1..1codeMime type of the content, with charset etc.
.... data 1..1base64BinaryData inline, base64ed

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical 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: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..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 S0..*Reference(CarePlan | ImmunizationRecommendation | NutritionOrder | MedicationRequest | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category SΣ0..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Group | Device | Location | Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(CareTeam | Organization | Practitioner | PractitionerRole)Responsible Diagnostic Service
... resultsInterpreter SΣ1..*Reference(CareTeam | Practitioner | Organization | PractitionerRole)Primary result interpreter
... specimen S0..*Reference(Specimen)Specimens this report is based on
... result S1..*Reference(Observation)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion S1..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... presentedForm 0..*AttachmentEntire report as issued
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... contentType Σ1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
.... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.


Example General: en-AU
.... data 1..1base64BinaryData inline, base64ed
.... url Σ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
.... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
.... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
.... creation Σ0..1dateTimeDate attachment was first created

doco Documentation for this format

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