diagnostics-documents

Generate DiagnosticReport resources (lab, radiology, pathology, cardiology) and DocumentReference resources (discharge summaries, consultation notes, progress notes, procedure notes). Use when user me

SKILL.md

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Diagnostics and Documents

Diagnostic Reports

  • Status: registered, partial, preliminary, final, amended, corrected, appended, cancelled, entered-in-error.
  • Categories: LAB (laboratory), RAD (radiology), PAT (pathology), CRD (cardiology).
  • Include DiagnosticReport.result[] referencing Observation resources.
  • For pathology: include conclusion and conclusionCode.
  • For radiology: include presentedForm (narrative report text as attachment).
  • Use effectiveDateTime or effectivePeriod for specimen collection timing.

Document References

  • Types (LOINC): 34133-9 (Summary of episode), 18842-5 (Discharge summary), 11488-4 (Consultation note), 11506-3 (Progress note), 28570-0 (Procedure note), 57133-1 (Referral note), 34117-2 (History and physical), 11504-8 (Surgical op note).
  • Status: current, superseded, entered-in-error.
  • Content: Include content[].attachment with contentType (application/pdf, text/plain), title, and creation date. Use data (base64) or url.
  • Context: Link to encounter, period, facilityType, practiceSetting.