Concepts/Diagnostic Report

Definition

A diagnostic report in Care holds the result of a laboratory, imaging, or other diagnostic service request. Each diagnostic report answers one service request. Care takes the patient, the encounter, and the facility from that service request. The report groups the individual result values, a written conclusion, and the attached result documents in one place.

Key Attributes

Components	What it captures
Status	The stage the report has reached, from first registration to the final result.
Category	The diagnostic service section that produced the result, such as the laboratory section or the imaging section. A report has one category.
Code	The test or observation that the report is about. This attribute uses a LOINC code and is optional.
Note	Extra remarks about the report.
Conclusion	A free text summary of the result.
Observations	The individual result values that belong to the report.

Service request

A diagnostic report always belongs to one service request. You do not select a patient, an encounter, or a facility on the report. Care takes all three from the service request that the report answers.

Observations

The observations hold the measured or observed result values. You can add or change observations while the status of the report is not Final. After you set the status to Final, Care locks the observations. You cannot add a new observation or change an existing one.

Attachments

A diagnostic report can carry file attachments, such as a scanned copy of a printed report. Care stores these files with the Files feature and attaches them to the report.

Specimen

Care does not link a diagnostic report to a specimen directly. A report and a specimen connect to each other only through the service request that they share.

Status

Status	Description
Registered	A user started the report, but the report holds no results yet.
Preliminary	The report holds early results that can still change.
Partial	The report holds some, but not all, of the expected results.
Final	The report is complete. Care locks the results against further changes.

Care uses these four statuses only. Care does not enforce an order between them. Any user with the correct permission can set any of the four statuses directly.

Permissions

Permission	Roles
Can Create Diagnostic Report on Facility	Facility Admin, Admin, Doctor, Nurse
Can Read Diagnostic Report	Facility Admin, Administrator, Admin, Staff, Doctor, Nurse, Volunteer

You need Can Create Diagnostic Report on Facility to create or update a diagnostic report. You need Can Read Diagnostic Report to view a diagnostic report.

Where to find it

Care shows diagnostic reports on the Diagnostic Reports tab of an encounter. You fill in a report from the detail page of its service request.

Pages that link here:

Concept: Concepts/Patient
Reference: References/Diagnostic Report