Breast Imaging Reporting - 2nd STU ballot
0.3.0 - CI Build United States of America flag

Breast Imaging Reporting - 2nd STU ballot, published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.3.0). This version is based on the current content of https://github.com/HL7/fhir-breast-radiology-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Breast Imaging Report

Official URL: http://hl7.org/fhir/us/breast-radiology/StructureDefinition/BreastImagingReport Version: 0.3.0
Draft as of 2019-11-01 Computable Name: BreastImagingReport

Breast Imaging Diagnostic Report.

Description

This resource is one of the components of a Breast Imaging Composition.

Each Breast Imaging Composition will contain exactly one Breast Imaging Report instance that is referenced in the composition's 'Report' section.

This instance will contain the top level results of the exam, including the narrative result.

The report may be a 'traditional' mammography report, or it may be a newer type of report such as a "3D mammography exam report". The Breast Imaging Document contains sections for commonly used modalities such as mammography, ultrasource and nuclear medicine, and also has a place for 'other' modalities.

Graphical Overview

This graph provides an overview of this profile, and its dependencies.

Click on any of the elements of the graph to go to a section describing that element.

image/svg+xml

Usage:

  • Refer to this Resource Profile:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for category 1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
.... category:categoryImaging 1..1CodeableConceptService category
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
... code 1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... specimen 0..0
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:categoryImaging SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:categoryImagingexamplePattern: imaging
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:categoryImaging SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:categoryImagingexamplePattern: imaging
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Mandatory: 1 element
Prohibited: 2 elements

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category is sliced based on the value of pattern:$this
  • The element DiagnosticReport.conclusionCode is sliced based on the value of pattern:$this

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for category 1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
.... category:categoryImaging 1..1CodeableConceptService category
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
... code 1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... specimen 0..0
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:categoryImaging SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:categoryImagingexamplePattern: imaging
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:categoryImaging SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: imaging
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: Breast Imaging Report Types ValueSet (required)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... Slices for conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


.... conclusionCode:BiRads 0..1CodeableConceptBiRads assessment value.
Binding: Breast Assessment Category ValueSet (required)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:categoryImagingexamplePattern: imaging
DiagnosticReport.coderequiredBreastImagingReportTypesVS
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
DiagnosticReport.conclusionCode:BiRadsrequiredBreastAssessmentCategoryVS

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Mandatory: 1 element
Prohibited: 2 elements

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category is sliced based on the value of pattern:$this
  • The element DiagnosticReport.conclusionCode is sliced based on the value of pattern:$this

 

Other representations of profile: CSV, Excel, Schematron