Identificador lógico deste artefato

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Idioma do conteúdo do recurso

Resumo do texto do recurso

Recursos contidos neste artefato

Conteúdo adicional definido por implementações

Extensão que não pode ser ignorada

Identificador do relatório

O que foi solicitado

O status do relatório de diagnóstico, a saber: registrado, parcial, preliminar, final

Categoria do serviço SADT que emitiu o relatório

Códigos que descrevem os relatórios de diagnóstico

O sujeito do relatório, geralmente, o paciente

ID exclusivo para referência entre elemento

Conteúdo adicional definido pelas implementações

Referência literal, URL relativa, interna ou absoluta

Tipo da referência a que o relatório se refere, por exemplo paciente

Referência lógica, quando a referência literal não é conhecida

Texto alternativo para o recurso

Atendimento no qual o procedimento foi solicitado

Tempo/período clinicamente relevante para o relatório

ID exclusivo para referência entre elementos

Utilizado para especificar o porquê do valor esperado não estar presente

Data e hora que esta versão foi feita

Responsável pelo SADT

Intérprete dos resultados primários

Amostras que este relatório se baseia

Observações, resultados e interpretações

Referência aos detalhes completos de imagens associadas ao relatório de diagnóstico

Principais imagens associadas a este relatório

ID exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Comentário sobre a imagem (por exemplo, explicação)

Referência à fonte da imagem

Conclusão clínica (interpretação) dos resultados dos testes

Códigos para a conclusão clínica dos resultados dos testes

Relatório completo conforme emitido

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.

This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Idioma do conteúdo do recurso

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

Resumo do texto do recurso

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Recursos contidos neste artefato

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Conteúdo adicional definido por implementações

Extensão que não pode ser ignorada

Identificador do relatório

Usually assigned by the Information System of the diagnostic service provider (filler id).

Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.

O que foi solicitado

Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.

This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

O status do relatório de diagnóstico, a saber: registrado, parcial, preliminar, final

The status of the diagnostic report.

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

Categoria do serviço SADT que emitiu o relatório

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Codes for diagnostic service sections.

Códigos que descrevem os relatórios de diagnóstico

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Codes that describe Diagnostic Reports.

O sujeito do relatório, geralmente, o paciente

SHALL know the subject context.

ID exclusivo para referência entre elemento

Conteúdo adicional definido pelas implementações

Referência literal, URL relativa, interna ou absoluta

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Tipo da referência a que o relatório se refere, por exemplo paciente

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

Referência lógica, quando a referência literal não é conhecida

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Texto alternativo para o recurso

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Atendimento no qual o procedimento foi solicitado

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

Links the request to the Encounter context.

Tempo/período clinicamente relevante para o relatório

If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.

Need to know where in the patient history to file/present this report.

ID exclusivo para referência entre elementos

Utilizado para especificar o porquê do valor esperado não estar presente

Data e hora que esta versão foi feita

May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

Clinicians need to be able to check the date that the report was released.

Responsável pelo SADT

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Intérprete dos resultados primários

Might not be the same entity that takes responsibility for the clinical report.

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Amostras que este relatório se baseia

If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.

Need to be able to report information about the collected specimens on which the report is based.

Observation results included in the diagnostic report.

Observations can contain observations.

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Observações, resultados e interpretações

Observations can contain observations.

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Referência aos detalhes completos de imagens associadas ao relatório de diagnóstico

ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.

Principais imagens associadas a este relatório

Many diagnostic services include images in the report as part of their service.

ID exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Comentário sobre a imagem (por exemplo, explicação)

The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.

The provider of the report should make a comment about each image included in the report.

Referência à fonte da imagem

Conclusão clínica (interpretação) dos resultados dos testes

Need to be able to provide a conclusion that is not lost among the basic result data.

Códigos para a conclusão clínica dos resultados dos testes

Diagnosis codes provided as adjuncts to the report.

Relatório completo conforme emitido

"application/pdf" is recommended as the most reliable and interoperable in this context.

Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.

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.

This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Idioma do conteúdo do recurso

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

Resumo do texto do recurso

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Recursos contidos neste artefato

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Conteúdo adicional definido por implementações

Extensão que não pode ser ignorada

Identificador do relatório

Usually assigned by the Information System of the diagnostic service provider (filler id).

Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.

O que foi solicitado

Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.

This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

O status do relatório de diagnóstico, a saber: registrado, parcial, preliminar, final

The status of the diagnostic report.

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

Categoria do serviço SADT que emitiu o relatório

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Codes for diagnostic service sections.

Códigos que descrevem os relatórios de diagnóstico

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Codes that describe Diagnostic Reports.

O sujeito do relatório, geralmente, o paciente

SHALL know the subject context.

ID exclusivo para referência entre elemento

Conteúdo adicional definido pelas implementações

Referência literal, URL relativa, interna ou absoluta

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Tipo da referência a que o relatório se refere, por exemplo paciente

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

Referência lógica, quando a referência literal não é conhecida

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Texto alternativo para o recurso

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Atendimento no qual o procedimento foi solicitado

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

Links the request to the Encounter context.

Tempo/período clinicamente relevante para o relatório

If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.

Need to know where in the patient history to file/present this report.

ID exclusivo para referência entre elementos

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Utilizado para especificar o porquê do valor esperado não estar presente

Data e hora que esta versão foi feita

May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

Clinicians need to be able to check the date that the report was released.

Responsável pelo SADT

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Intérprete dos resultados primários

Might not be the same entity that takes responsibility for the clinical report.

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Amostras que este relatório se baseia

If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.

Need to be able to report information about the collected specimens on which the report is based.

Observation results included in the diagnostic report.

Observations can contain observations.

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Observações, resultados e interpretações

Observations can contain observations.

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Referência aos detalhes completos de imagens associadas ao relatório de diagnóstico

ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.

Principais imagens associadas a este relatório

Many diagnostic services include images in the report as part of their service.

ID exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Comentário sobre a imagem (por exemplo, explicação)

The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.

The provider of the report should make a comment about each image included in the report.

Referência à fonte da imagem

Conclusão clínica (interpretação) dos resultados dos testes

Need to be able to provide a conclusion that is not lost among the basic result data.

Códigos para a conclusão clínica dos resultados dos testes

Diagnosis codes provided as adjuncts to the report.

Relatório completo conforme emitido

"application/pdf" is recommended as the most reliable and interoperable in this context.

Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.