description: Imaging report reflects the observations and interpretations of one or more imaging studies, contains elements such as the reason why the study is requested, relevant contextual medical information, the modality used to acquire images and its settings, procedures and body localisations that were used, a description of the observations and findings, exposure information, conclusion and advice.
package_name: xtehr.eu.ehds.models
derivation: specialization
name: EHDSImagingReport
type: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImagingReport
elements:
  header:
    short: Imaging report header
    index: 0
    elements:
      author:
        short: The author of the report.
        choices: []
        index: 2
      status: {short: Status of the report, index: 3}
      documentType: {short: Type of document (e.g. 18748-4 Diagnostic imaging study), index: 4}
      eventType: {short: 'Categorisation of the event covered by the document (e.g. imaging study types, body regions, modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.', index: 5}
      accessionNumber: {type: Identifier, short: 'Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s).', array: true, index: 6}
      intendedRecipient:
        short: Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
        choices: ['intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice']
        array: true
        index: 8
      intendedRecipientHttp://www:
        elements:
          xt-ehr:
            elements:
              eu/fhir/models/StructureDefinition/EHDSPatient: {short: 'Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient', array: true, choiceOf: intendedRecipient, index: 9}
              eu/fhir/models/StructureDefinition/EHDSRelatedPerson: {short: 'Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson', array: true, choiceOf: intendedRecipient, index: 10}
              eu/fhir/models/StructureDefinition/EHDSHealthProfessional: {short: 'Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', array: true, choiceOf: intendedRecipient, index: 11}
              eu/fhir/models/StructureDefinition/EHDSOrganisation: {short: 'Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation', array: true, choiceOf: intendedRecipient, index: 12}
              eu/fhir/models/StructureDefinition/EHDSDevice: {short: 'Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice', array: true, choiceOf: intendedRecipient, index: 13}
  body:
    type: Base
    short: Imaging report structured body
    index: 14
    elements:
      orderInformation:
        type: Base
        short: Order Information (Imaging Result Report could respond to multiple orders).
        array: true
        index: 15
        elements:
          orderPlacer:
            short: The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.
            choices: ['orderPlacerHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', 'orderPlacerHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation', 'orderPlacerHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient']
            index: 19
          orderReasonString: {short: An explanation or justification for why this service is being requested., type: string, array: true, choiceOf: orderReason, index: 28}
          orderReason:
            short: An explanation or justification for why this service is being requested.
            choices: [orderReasonCodeableConcept, 'orderReasonHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', 'orderReasonHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', orderReasonString]
            array: true
            index: 24
          orderDateAndTime: {type: dateTime, short: Date and time of the order placement., index: 17}
          clinicalQuestion: {type: string, short: Specification of clinical question (goal of the investigation) to be answered by the imaging investigation., index: 29}
          orderPlacerHttp://www:
            elements:
              xt-ehr:
                elements:
                  eu/fhir/models/StructureDefinition/EHDSHealthProfessional: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', short: 'The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.', choiceOf: orderPlacer, index: 20}
                  eu/fhir/models/StructureDefinition/EHDSOrganisation: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation', short: 'The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.', choiceOf: orderPlacer, index: 21}
                  eu/fhir/models/StructureDefinition/EHDSPatient: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient', short: 'The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.', choiceOf: orderPlacer, index: 22}
          orderReasonCodeableConcept: {short: An explanation or justification for why this service is being requested., type: CodeableConcept, array: true, choiceOf: orderReason, index: 25}
          orderReasonHttp://www:
            elements:
              xt-ehr:
                elements:
                  eu/fhir/models/StructureDefinition/EHDSCondition: {short: An explanation or justification for why this service is being requested., type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', array: true, choiceOf: orderReason, index: 26}
                  eu/fhir/models/StructureDefinition/EHDSObservation: {short: An explanation or justification for why this service is being requested., type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', array: true, choiceOf: orderReason, index: 27}
          orderId: {type: Identifier, short: Identifier(s) of the imaging service order., array: true, min: 1, index: 16}
        required: [orderId]
      supportingInformation:
        type: Base
        short: Additional clinical information about the patient or specimen that may affect service delivery or interpretation (additional types of information may be allowed in implementations).
        index: 30
        elements:
          observation: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', short: 'Clinical findings and other observations (e.g., height and weights of the patient).', array: true, index: 31}
          condition: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', short: Conditions that may influence the service or result interpretation., array: true, index: 32}
          priorMedicationAdministration: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationAdministration', short: Medication administered before ordering the service specifically for this procedure., array: true, index: 33}
          device: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse', short: List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants)., array: true, index: 34}
          pregnancyStatus: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCurrentPregnancy', short: 'Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).', index: 35}
          sexForClinicalUse: {type: CodeableConcept, short: 'Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.', index: 36}
      specimen: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSpecimen', short: 'Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.', array: true, index: 37}
      serviceRequest: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSServiceRequest', short: Specification of requested service(s)., array: true, index: 38}
      exposureInformation: {type: string, short: Information on total exposure to ionising radiation. This information is required by regulations in several EU countries., index: 39}
      examinationReport:
        type: Base
        short: Examination report content.
        index: 40
        elements:
          conclusion:
            type: Base
            short: A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.
            index: 50
            elements:
              impression: {type: string, short: Narrative description of the clinical conclusion (impression)., index: 51}
              conditionOrFinding:
                short: Condition or finding from imaging investigation.
                choices: ['conditionOrFindingHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', 'conditionOrFindingHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation']
                array: true
                index: 53
              conditionOrFindingHttp://www:
                elements:
                  xt-ehr:
                    elements:
                      eu/fhir/models/StructureDefinition/EHDSCondition: {short: Condition or finding from imaging investigation., type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', array: true, choiceOf: conditionOrFinding, index: 54}
                      eu/fhir/models/StructureDefinition/EHDSObservation: {short: Condition or finding from imaging investigation., type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', array: true, choiceOf: conditionOrFinding, index: 55}
            required: [impression]
          adverseReaction: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntolerance', short: Adverse reactions manifested during imaging investigation., array: true, index: 45}
          medicationAdministration: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationAdministration', short: 'Information about medications administered (contrast, sedation, stress agents, etc) during the procedure.', array: true, index: 44}
          modality: {min: 1, short: Imaging modality (or modalities) used during imaging investigation (DICOM CID029)., type: CodeableConcept, array: true, index: 41}
          resultsString: {short: Imaging report result data (report could consist of multiple observations), type: string, array: true, choiceOf: results, index: 49}
          resultsHttp://www:
            elements:
              xt-ehr:
                elements:
                  eu/fhir/models/StructureDefinition/EHDSObservation: {short: Imaging report result data (report could consist of multiple observations), type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', array: true, choiceOf: results, index: 48}
          bodySite: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSBodyStructure', short: All body parts investigated, array: true, index: 42}
          imagingProcedures: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure', short: Imaging procedure performed during imaging study., array: true, index: 43}
          results:
            short: Imaging report result data (report could consist of multiple observations)
            choices: ['resultsHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', resultsString]
            array: true
            index: 47
        required: [modality]
      recommendation:
        type: Base
        short: Recommendation section for additional imaging tests or other actions
        index: 56
        elements:
          description: {type: string, short: 'Narrative description of the recommended activities including additional test, medication etc.', index: 57}
          carePlan: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan', short: 'A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.', array: true, index: 58}
        required: [description]
      comparisonStudy: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImagingReport', short: Documentation (reference) of a prior Imaging Report to which the current images were compared., array: true, index: 59}
    required: [examinationReport]
  dicomStudyMetadata: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImagingStudy', short: 'Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.', array: true, index: 60}
  attachments: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment', short: Report attachments, array: true, index: 61}
package_version: 0.3.0
class: logical
kind: logical
url: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImagingReport
base: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDocument
version: 0.3.0