> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Diagnostic Reports and Observations
> How to record and manage structured clinical observations, imaging results, and diagnostic reports for investigations beyond standard lab tests.
Not all clinical investigations follow the same path as a blood test. When a patient has an X-ray, an ultrasound, an ECG reading, or a clinical survey, the results need to be stored in a structured format and linked to the patient's record. The Observations and Diagnostic Reports module handles this.
A **Diagnostic Report** is the final document - like a radiology report or an ECG interpretation. It groups one or more **Observations**, which are the individual measurements or findings within that report.
***
## When to Use This Module vs the Laboratory Module
| Use Diagnostic Reports for | Use the Laboratory module for |
| ------------------------------------------------------------------------ | ---------------------------------------------------- |
| Radiology results (X-ray, ultrasound, CT scan) | Blood tests, urine tests, cultures |
| ECG readings and interpretations | Haematology, biochemistry, microbiology panels |
| Clinical surveys and scoring tools | Tests with numeric parameters and normal ranges |
| Imaging reports from external facilities | Tests processed in the clinic's own lab |
| Any finding that is better described as text or a category than a number | Tests with a standardised sample-collection workflow |
***
## Before You Start
* **Observation Templates** must be set up for each type of observation your clinic records.
* You need the **Healthcare Practitioner** or **Healthcare Administrator** role.
* Service Requests are used to formally order observations before creating a Diagnostic Report.
***
## Step 1: Set Up Observation Templates (Admin Task)
An Observation Template defines what a particular type of observation measures.
1. Go to Healthcare workspace → Diagnostic Module card → **Observation Template** → New
| Field | What to Configure |
| --------------------------- | --------------------------------------------------------------------------------------------------- |
| Observation | Name of the observation (e.g., "Chest X-Ray", "ECG Rhythm", "Blood Pressure Reading") |
| Observation Category | Imaging, Laboratory, Vital Signs, Procedure, Survey, Exam, Therapy, Activity, or Social History |
| Permitted Data Type | How the result will be recorded: Numeric, Text, Select (choose from options), Boolean, Attach, etc. |
| Permitted Unit | Unit of measurement (if numeric) |
| Sample | Sample type needed (if any) |
| Observation Reference Range | Normal range for numeric observations |
| Is Billable | Whether this observation generates a billing charge |
| Rate | Standard fee if billable |
***
## Step 2: Create an Observation
Each individual finding is an Observation record.
1. Go to Healthcare workspace → Diagnostic Module card → **Observation** → New
2. Fill in the key fields:
| Field | What to Enter |
| ----------------------- | ----------------------------------------------------------------------------------------- |
| Patient | The patient this observation is for |
| Observation Template | What is being recorded (from template setup) |
| Observation Category | Imaging, Vital Signs, Laboratory, etc. |
| Status | Registered → Preliminary → Final → Approved |
| Result | The finding - text, number, image attachment, or selection depending on the template type |
| Healthcare Practitioner | Who recorded or ordered the observation |
| Company | Your clinic |
For numeric observations, enter the value in the **Result** (numeric) field.
For text findings (e.g., radiology interpretation), enter in the **Result** (text) field.
For attachments (e.g., scanned report PDF), use **Attach Result**.
3. Set the status to **Final** when the finding is complete
4. Submit the Observation
***
## Step 3: Create a Diagnostic Report
A Diagnostic Report groups related observations into a single document - for example, grouping the right lung observation and the left lung observation into one "Chest X-Ray Report."
1. Go to Healthcare workspace → Diagnostic Module card → **Diagnostic Report** → New
2. Fill in the details:
| Field | What to Enter |
| ---------------------- | ---------------------------------------------------------------- |
| Patient | The patient this report is for |
| Practitioner | The doctor or specialist producing the report |
| Reference Posting Date | Date the report was produced |
| Status | Open → Pending Review → Partially Approved → Approved → Rejected |
3. The report links to its individual Observation records automatically through the reference fields
4. Set the status to **Approved** once the doctor has reviewed and signed off
***
## Observation Statuses
| Status | What It Means |
| ----------- | ---------------------------------------------------------- |
| Registered | Observation ordered, not yet recorded |
| Preliminary | Initial finding entered, may be revised |
| Final | Finding is complete and confirmed |
| Amended | A correction was made after finalisation |
| Corrected | Corrected version of a previously released observation |
| Approved | Reviewed and released by authorised clinician |
| Rejected | Finding rejected (incorrect template, wrong patient, etc.) |
***
## Diagnostic Report Statuses
| Status | What It Means |
| ------------------ | --------------------------------------------------- |
| Open | Report created, findings being gathered |
| Pending Review | All observations entered, waiting for doctor review |
| Partially Approved | Some observations approved, others pending |
| Approved | All findings reviewed and approved |
| Rejected | Report rejected and discarded |
***
## Field Guide: Observation
| Field | What It Contains |
| ----------------------------------- | ------------------------------------------------ |
| Patient | The patient the observation is for |
| Observation Template | Template defining what is being observed |
| Observation Category | Type (Imaging, Vital Signs, Laboratory, etc.) |
| Status | Current stage of the observation |
| Result (numeric/text/select/attach) | The actual finding |
| Healthcare Practitioner | Who recorded it |
| Sample Collection Required | Whether a sample needs to be taken |
| Specimen | The specimen record if sample-based |
| Service Request | The formal order that triggered this observation |
| Invoiced | Whether this observation has been billed |
| Sales Invoice | Linked invoice if billed |
***
## Field Guide: Diagnostic Report
| Field | What It Contains |
| ---------------------- | ------------------------------------------------------------ |
| Patient | The patient the report is for |
| Practitioner | The reporting clinician |
| Status | Open, Pending Review, Partially Approved, Approved, Rejected |
| Reference Posting Date | Date of the report |
| Sample Collection | If a sample was involved |
| Sales Invoice Status | Billing status |
***
## Troubleshooting
**I cannot find the Diagnostic Module card on the workspace**
Scroll down the workspace to the second row of cards. The Diagnostic Module card contains Diagnostic Report, Observation, and Observation Template.
**The result field is not showing on the Observation form**
The Permitted Data Type on the Observation Template determines which result field appears. If "Attach" is selected, you will see an attachment button rather than a text or number field. If no type is selected, configure it in the template first.
**A Diagnostic Report has been approved but the patient cannot see it in the portal**
Diagnostic Reports are not yet surfaced in the standard patient portal. The patient can receive the report by email or printed copy.
***
## Best Practices
* Use Observation Templates for every investigation type you regularly perform - do not enter free-text observations without a template, as this makes them unsearchable and unbillable
* For imaging results from external facilities, create the Observation as an "Attach" type and upload the scanned report - this ensures it is stored in the patient's history
* Approve Diagnostic Reports within the same working day they are completed - leaving reports in "Pending Review" means the doctor's interpretation is not officially recorded
* For ECG and radiology, include the doctor's text interpretation in the description field alongside the raw measurement or image - the raw attachment alone is not useful for future reference
* Link the Observation or Diagnostic Report to the Service Request that ordered it (reference fields) so that billing can be tracked end to end
***
## Related Features
* [Consultations](/health-wellness/general-clinic/consultations): Investigations may be ordered from the Patient Encounter
* [Laboratory](/health-wellness/general-clinic/laboratory): For standard blood and urine tests with numeric parameters and normal ranges
* [Billing and Finance](/health-wellness/general-clinic/billing-finance): Billable observations are invoiced like other services