International Patient Summary Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions
Page standards status: Informative |
<Observation xmlns="http://hl7.org/fhir">
<!-- TRILLIUM II Project
Example of imaging observation including the information of example 2 (some essential and contextual data ) plus:
- reason For Study (example 3)
- target region (example 3)
- acquisition device (example 3)
- list of evidence references (example 3)
- reference to the report
Only textual results including overall result and findings
-->
<id value="ips-example-imaging-4"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>
<b>date</b>: 1995-06-08
</p>
<p>
<b>subject</b>: <a>Patient/eumfh-39-07</a>
</p>
<p>
<b>CT Abdomen W contrast IV</b>
</p>
<p>
<b>Procedure Description:</b>Serial imaging was obtained in the upper abdomen with the administration of oral and intravenous contrast.</p>
<p>
<b>Finding:</b>The examination demonstrates a well circumscribed 3 cm lesion present within the medial aspect of the inferior right liver lobe. Initial evaluation demonstrates lack of contrast enhancement. Subsequent imaging (not shown) demonstrated typical contrast enhancement pattern of a benign hemangioma of the liver. The remaining contrast enhancement pattern in the liver is normal. There is normal appearance of the adrenal glands, spleen, kidneys, and pancreas. There is no evidence of liver metastasis.</p>
<p>
<b>Conclusion:</b>3 cm nodule present in the inferior medial aspect of right liver lobe. Contrast enhancement pattern consistent with the diagnosis of hemangioma.
</p>
</div>
</text>
<partOf>🔗
<reference value="ImagingStudy/TII-ImagingStudy-5-1"/>
</partOf>
<status value="final"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/observation-category"/>
<code value="imaging"/>
<display value="Imaging"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="79103-8"/>
<display value="CT Abdomen W contrast IV"/>
</coding>
<text
value="Upper abdomen with the administration of oral and intravenous contrast (example-4)"/>
</code>
<!-- in the profile effectiveTime is 0...1 so it can be omitted -->
<subject>🔗
<reference value="Patient/eumfh-39-07"/>
</subject>
<effectiveDateTime value="1995-06-08"/>
<performer>🔗
<reference value="Practitioner/eumfh-39-07"/>
</performer>
<performer>🔗
<reference value="Organization/TII-Organization1"/>
</performer>
<valueString
value="3 cm nodule present in the inferior medial aspect of right liver lobe. Contrast enhancement pattern consistent with the diagnosis of hemangioma."/>
<component>
<code>
<coding>
<system value="http://dicom.nema.org/resources/ontology/DCM"/>
<code value="121065"/>
<display value="Procedure Description"/>
</coding>
</code>
<valueString
value="Serial imaging was obtained in the upper abdomen with the administration of oral and intravenous contrast."/>
</component>
<component>
<code>
<coding>
<system value="http://dicom.nema.org/resources/ontology/DCM"/>
<code value="121071"/>
<display value="Finding"/>
</coding>
</code>
<valueString
value="The examination demonstrates a well circumscribed 3 cm lesion present within the medial aspect of the inferior right liver lobe. Initial evaluation demonstrates lack of contrast enhancement. Subsequent imaging (not shown) demonstrated typical contrast enhancement pattern of a benign hemangioma of the liver. The remaining contrast enhancement pattern in the liver is normal. There is normal appearance of the adrenal glands, spleen, kidneys, and pancreas. There is no evidence of liver metastasis."/>
</component>
</Observation>