Diagnostic Report Resource

Overview

The DiagnosticReport resource represents the findings and interpretation of diagnostic tests performed on patients. It includes imaging studies, laboratory tests, and other clinical assessments, providing both structured data and narrative results.

Critical Components

Field	Description	Standard Values/Examples
`resourceType`	Always "DiagnosticReport"	"DiagnosticReport"
`id`	Unique identifier for the report	"1342252"
`meta`	Contains version information and metadata	Includes `versionId`, `lastUpdated`, and `profile`
`status`	Current state of the report	Standard Values: "registered", "partial", "preliminary", "final", "amended", "corrected", "appended", "cancelled", "entered-in-error", "unknown"
`category`	Classification of the diagnostic discipline	Common categories include: "LAB" (Laboratory), "RAD" (Radiology), "PATH" (Pathology)
`code`	Type of diagnostic report	Typically uses LOINC codes
`subject`	Reference to the patient	Format: "Patient/[ID]"
`encounter`	Encounter during which test was performed	References Encounter resources
`effectiveDateTime`	When the test was performed	ISO 8601 datetime format
`issued`	When the report was issued	ISO 8601 datetime format
`performer`	Who was responsible for the report	References Practitioner resources
`resultsInterpreter`	Who interpreted the results	References Practitioner resources
`imagingStudy`	Reference to the actual imaging study	References ImagingStudy resources
`conclusion`	Clinical conclusion (interpretation)	Text summary of the findings
`conclusionCode`	Coded diagnosis from the report	Typically uses SNOMED CT codes
`presentedForm`	Entire report as an attachment	Base64-encoded content with specified mime type

Example:

{
    "resourceType": "DiagnosticReport",
    "id": "1342252",
    "meta": {
        "versionId": "1",
        "lastUpdated": "2025-03-20T14:26:04.610+00:00",
        "source": "#ed3cad9d11c38d38",
        "profile": [
            "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note"
        ]
    },
    "status": "final",
    "category": [
        {
            "coding": [
                {
                    "system": "http://loinc.org",
                    "code": "LP29684-5",
                    "display": "Radiology"
                }
            ]
        }
    ],
    "code": {
        "coding": [
            {
                "system": "http://loinc.org",
                "code": "24725-2",
                "display": "CT Head WO Contrast"
            }
        ],
        "text": "CT Head without contrast"
    },
    "subject": {"reference": "Patient/CR7794222774698-5"},
    "encounter": {"reference": "Encounter/encounter-ed-345678"},
    "effectiveDateTime": "2025-03-10T10:15:00Z",
    "issued": "2025-03-10T10:45:00Z",
    "performer": [
        {
            "reference": "Practitioner/radiologist-456789",
            "display": "Dr. Michael Wong"
        }
    ],
    "resultsInterpreter": [
        {
            "reference": "Practitioner/radiologist-456789",
            "display": "Dr. Michael Wong"
        }
    ],
    "imagingStudy": [{"reference": "ImagingStudy/imaging-study-ct-head"}],
    "conclusion": "Mild contusion in the left temporoparietal region. No evidence of intracranial hemorrhage. No skull fracture identified. Mild age-appropriate brain volume loss. Cerebral ventricles are normal in size.",
    "conclusionCode": [
        {
            "coding": [
                {
                    "system": "http://snomed.info/sct",
                    "code": "45372005",
                    "display": "Cerebral contusion"
                }
            ]
        }
    ],
    "presentedForm": [
        {
            "contentType": "text/plain",
            "data": "BASE64-ENCODED-CONTENT",
            "title": "CT Head Report"
        }
    ]
}

Key Details

Different Types of DiagnosticReports

Laboratory Reports: Blood tests, urine analysis, etc.
Imaging Reports: X-rays, CT scans, MRIs, ultrasound
Pathology Reports: Tissue biopsies, cytology
Cardiology Reports: ECGs, stress tests
Genomics Reports: Genetic tests

DiagnosticReport often functions as a container that references individual Observation resources (not shown in this example) for specific test results.

Common Coding Systems

LOINC (http://loinc.org): For report types and categories
SNOMED CT (http://snomed.info/sct): For clinical findings

Links to Patient resources via subject
Links to Encounter resources via encounter
Links to Practitioner resources via performer and resultsInterpreter
Links to ImagingStudy resources via imagingStudy
May reference Observation resources via result (not shown in example)
May reference Specimen resources via specimen (not shown in example)

Diagnostic Report Resource

Diagnostic Report Resource

Overview

Critical Components

Example:

Key Details

Different Types of DiagnosticReports

Related Observation Resources

Common Coding Systems

Related Resources