工作组: Orders and Observations & Clinical Genomics 标准状态: Informative

辅助诊断组件提供了FHIR中涉及临床诊断的医嘱和报告的相关内容与指南,包括实验室检验、影像检查和基因检测。

辅助诊断组件包含了下列资源:

辅助诊断资源及其关系如下所示。箭头表示资源之间引用的方向(例如,诊断报告资源DiagnosticReport引用服务申请资源ServiceRequest)。 欲了解活动协作的相关信息,如辅助诊断的申请与完成,请参阅工作流组件

Image showing the diagnostic resources

实施说明:有关如何使用辅助诊断资源进行临床基因组报告和分析的更多信息,请参阅基因组学实施指南

名称其它称谓描述
Observation生命体征、测量、结果 关于患者、设备或其他目标的测量和简洁断言
DiagnosticReport报告、检测、结果、试验 对患者、患者组、设备、位置或从中提取的标本进行的诊断试验的结果和解释。此报告包括了临床场景(如申请单、提供者信息),有些报告将单项指标结果、图像、文本和带编码的解释、以及带格式的诊断报告混合在一起。
ServiceRequest 诊断申请、转诊、转诊申请 服务申请的记录,如诊断循症、治疗或要执行的操作。
Media 在卫生健康领域获取或使用的照片、视频或音频记录。实际内容可以是内置的,也可以由直接引用提供。
ImagingStudy 对DICOM成像研究中产生内容的表示。成像研究资源ImagingStudy包括一组序列,其中每个序列又包含一组在通用场景中获取或生成的实例(SOP实例:图像或其他数据),每个实例都是成对出现的服务与对象。一个序列只有一种形式(如X光、CT、MR、超声波),但一个ImagingStudy可能有多个不同的形式的序列。
MolecularSequence 描述生物序列的原始数据。
Specimen 用于分析的样本。
BodyStructure解剖部位 记录有关解剖结构的详细信息。没有编码概念可以为用例提供所需的必要细节时,可以使用此资源。

辅助诊断资源通常代表特定于患者的数据,因此容易受到数据破坏的影响。在搜索和获取此信息时,必须制定必要的隐私和安全规定。 有关更一般的注意事项,请参阅安全与隐私组件

辅助诊断资源通常用于计划、推荐、下达和报告临床诊断:

有很多方法可以独立地使用这些资源。特别是观测资源,在卫生健康领域中,许多测量和事件都是围绕着它来进行的,观测资源还常用于辅助诊断医嘱和报告之外的场境。

  • 记录生命体征,如 体温
  • 记录患者社会史的其他观测结果,如吸烟史
  • 记录患者的其他特征,如妊娠状态(注:也可用病症情况资源Condition来表示)
  • 记录临床评估工具评分,如。Apgar 评分.
  • 识别和描述 标本身体部位

管理组件中可以找到代表患者基本信息和临床就诊信息的资源。 其他代表卫生健康提供者在患者就诊过程中产生的核心临床信息的资源在 临床摘要组件药物组件中详细介绍。

  • The Observation and Diagnostic Report resources have been tested and used in production tooling and as such have reached a maturity level FMM=4 where changes become less likely and require implementer community approval. Future work will focus on developing core profiles and clarifying use cases and boundaries and providing more domain specific examples. We anticipate Observation and Diagnostic Report reaching normative status by the end of this cycle.
  • The ImagingStudy resource has had some limited testing and use. Further use of this resource in production tooling is needed for it to reach a more stable FMM level.
  • The ServiceRequest resources has undergone substantial changes since DSTU2. Foremost of which is the merging of DSTU2 DiagnosticOrder and ServiceRequest into a single resource. In addition, as a result of the addition of FHIR workflow for STU3, its structure and content have been updated to align with the general FHIR workflow "request" pattern. Because of these, it remains a relatively immature resource. No more sweeping changes to its structure are expected. However, its scope and boundaries vis a vis other resources will be the topic of future workgroup efforts. We anticipate its broad use by implementers and that it will mature as a resource throughout the upcoming cycle.
  • The Specimen resource will be the focus of work group efforts for the upcoming cycle. A new SpecimenDefinition resource is planned for describing specimen types vs specimen instances and will take over some of the Specimen resource's current scope. We expect to see more widespread use of this resource and future updates to its FMM level
  • The MolecularSequence resource remains draft and we expect to see more widespread use of this resource and future updates to its FMM level
  • The BodyStructure resource is an immature resource with a FMM level of 1. To date there has been little implementation feedback.
  • The Media resource is the newest member to the Diagnostics module having undergone substantial scope and structural changes to create a specialized observation resource focused on digital media such as images and audio files. Future work will focus on developing core profiles and providing more domain specific examples.