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DiagnosticReport Profile

Canonical../StructureDefinition/nexus-emr-core-diagnosticreport
Statusdraft · 1.26.0
BaseDiagnosticReport (constraint)
SourceFSH · JSON

Defines the Nexus EMR FHIR profile for DiagnosticReport resources, based on CA-Core constraints, for aggregating diagnostic reports (e.g., Lab, Imaging) from multiple EMRs.

Overview

Overview

The Nexus EMR Core DiagnosticReport profile represents diagnostic test results including laboratory reports, imaging studies, pathology reports, and other diagnostic findings within primary care EMR systems. This profile serves as a container that groups related observations and provides clinical interpretation across the Nexus EMR ecosystem.

Key Features

  • Multi-format Support: Accommodates structured data and rendered reports (PDF, HTML)
  • Result Grouping: Links multiple related observations into cohesive reports
  • Interpretation Support: Captures clinical conclusions and coded findings
  • Version Management: Tracks preliminary, final, amended, and corrected reports
  • Flexible Coding: Supports LOINC and source EMR report type codes

Report Categories

Common diagnostic report types include:

  • Laboratory: Chemistry panels, hematology, microbiology, urinalysis
  • Radiology: X-rays, CT scans, MRI, ultrasound reports
  • Pathology: Biopsies, cytology, surgical pathology
  • Cardiology: ECG, echocardiogram, stress test results
  • Other Diagnostics: Pulmonary function tests, neurophysiology studies

Report Components

A complete diagnostic report includes:

  • Header: Report type, status, date/time
  • Results: Individual observation results with values and reference ranges
  • Interpretation: Clinical conclusions and findings
  • Rendered Form: Human-readable version (PDF/HTML)
  • Performers: Laboratory or diagnostic service responsible

Status Workflow

Reports progress through various states:

  • Registered: Order received, not yet started
  • Partial: Some results available
  • Preliminary: Initial results, not yet verified
  • Final: Complete and verified
  • Amended: Modified after final
  • Corrected: Error correction after final
  • Cancelled: Report withdrawn

Clinical Integration

DiagnosticReports connect to:

  • Observations: Individual test results and measurements
  • ServiceRequests: Orders that initiated the testing
  • Specimens: Samples analyzed (for lab reports)
  • Encounter: Clinical context when tests were ordered

Terminology bindings

Path Strength Value set
DiagnosticReport.status required diagnostic-report-status
DiagnosticReport.conclusionCode example clinical-findings