In addition to the method operations, according to the event summary's "updates can include" bullets: "updating attributes of the anchor context (the DiagnosticReport resource) or associated context resources (Patient and/or ImagingStudy resources)", the update event can also be used to update content of the anchor context or the Patient/ImagingStudy resources associated. That exchange has no examples nor any parameters to define the exchange. How can a consuming application tell: Were elements deleted? Added? Entire resource replaced? Will the resource's elements only be included as deltas?

I would propose that these updates should either be included in the Bundle with their corresponding method operation (for example, with a DxReport anchor, include a PUT DxReport in the updates bundle to change an element) or they should be communicated in the form of Patient-update or ImagingStudy-update rather than implicit changes on non-required resources of DiagnosticReport-update events.