Identificador lógico deste artefato

Metadados sobre o recurso

Um conjunto de regras sob as quais este conteúdo foi criado

Idioma do recurso

Resumo do texto do recurso em linguagem natural

Recursos contidos no recurso

Extensões adicionais que não fazem parte do modelo base

Esta extensão representa uma conduta associada ao laudo, fornecendo orientações ou sugestões baseadas nos resultados do diagnóstico para o manejo clínico do paciente.

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

O que foi solicitado

O status do relatório de diagnóstico

Categoria do serviço

Nome/Código para este relatório de diagnóstico

O indivíduo do relatório - geralmente, mas nem sempre, o paciente

Evento de assistência médica quando o teste foi solicitado

Tempo/período de tempo clinicamente relevante para o relatório

Data e hora em que esta versão foi feita

Serviço de diagnóstico (SADT) responsável

Intérprete de resultado

Amostras deste relatório

Observations

Referência as imagens associadas ao relatório de diagnóstico ao relatório de diagnóstico

Imagens associadas a este relatório

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Comentário sobre a imagem

Referência à fonte da imagem

Conclusão clínica (interpretação) dos resultados

Códigos da conclusão clínica dos resultados

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

Um 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 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 em linguagem natural

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 no recurso

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.

Extensões adicionais que não fazem parte do modelo base

Esta extensão representa uma conduta associada ao laudo, fornecendo orientações ou sugestões baseadas nos resultados do diagnóstico para o manejo clínico do paciente.

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

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

The status of the diagnostic report.

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

Categoria do serviço

Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.

Nome/Código para este relatório de diagnóstico

Codes that describe Diagnostic Reports.

O indivíduo do relatório - geralmente, mas nem sempre, o paciente

SHALL know the subject context.

Evento de assistência médica quando o teste 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 de tempo 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.

Data e hora em 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.

Serviço de diagnóstico (SADT) responsável

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 de resultado

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 deste relatório

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.

Observations

Observations can contain observations.

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

Referência as imagens associadas ao relatório de diagnóstico 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.

Imagens associadas a este relatório

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

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Comentário sobre a imagem

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

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

Códigos da conclusão clínica dos resultados

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

Um 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 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 em linguagem natural

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 no recurso

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.

Extensões adicionais que não fazem parte do modelo base

Esta extensão representa uma conduta associada ao laudo, fornecendo orientações ou sugestões baseadas nos resultados do diagnóstico para o manejo clínico do paciente.

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

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

The status of the diagnostic report.

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

Categoria do serviço

Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.

Nome/Código para este relatório de diagnóstico

Codes that describe Diagnostic Reports.

O indivíduo do relatório - geralmente, mas nem sempre, o paciente

SHALL know the subject context.

Evento de assistência médica quando o teste 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 de tempo 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.

Data e hora em 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.

Serviço de diagnóstico (SADT) responsável

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 de resultado

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 deste relatório

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.

Observations

Observations can contain observations.

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

Referência as imagens associadas ao relatório de diagnóstico 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.

Imagens associadas a este relatório

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

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Comentário sobre a imagem

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

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

Códigos da conclusão clínica dos resultados

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.