Generated Narrative: Composition bundle-composition-imaging

status: Final

type: Informe de eventos de cáncer:{Configuración} :Punto temporal:Tipo:Documento:{Role}

date: 2026-01-20 10:30:00-0600

author: Dr. Carlos López Martínez, Radiólogo

title: Radiografía de Tórax - Reporte Final

 <section> <title value="Hallazgos Clínicos"/> <code> <coding> <system value="http://loinc.org"/> <code value="72131-6"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p><strong>Técnica:</strong> Radiografía de tórax posteroanterior (PA) y lateral.</p><p><strong>Hallazgos:</strong> Pulmones bien expandidos bilateralmente sin opacidades localizadas. Corazón de tamaño normal. Mediastino dentro de los límites normales. Diafragmas regulares y sin neumotórax. Hilios pulmonares normales.</p></div> </text> </section> <section> <title value="Impresión"/> <code> <coding> <system value="http://loinc.org"/> <code value="72132-4"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Radiografía de tórax normal. No se evidencian hallazgos patológicos agudos.</p></div> </text> </section> <section> <title value="Recomendaciones"/> <code> <coding> <system value="http://loinc.org"/> <code value="72133-2"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Seguimiento clínico según criterio médico. No se requieren estudios de imagen adicionales en este momento.</p></div> </text> </section> <section> <title value="Findings"/> <code> <coding> <system value="http://loinc.org"/> <code value="72131-6"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Observations and clinical findings from the imaging study.</p></div> </text> <entry> <reference value="urn:uuid:77777777-7777-7777-7777-777777777777"/> </entry> </section> </Composition> </resource> </entry> <entry> <fullUrl value="urn:uuid:22222222-2222-2222-2222-222222222222"/> <resource> <DiagnosticReport> <id value="bundle-diagnostic-report"/> <meta> <profile value="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-diagnostic-report"/> </meta> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="DiagnosticReport_bundle-diagnostic-report"> </a><p class="res-header-id"><b>Generated Narrative: DiagnosticReport bundle-diagnostic-report</b></p><a name="bundle-diagnostic-report"> </a><a name="hcbundle-diagnostic-report"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-cr-diagnostic-report.html">CR Diagnostic Report</a></p></div><h2><span title="Codes:{http://loinc.org 72134-0}">Radiografía de Tórax</span> (<span title="Codes:{https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections RAD}">RAD</span>) </h2><table class="grid"><tr><td>Subject</td><td>María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</td></tr><tr><td>When For</td><td>2026-01-20 09:15:00-0600</td></tr><tr><td>Reported</td><td>2026-01-20 10:30:00-0600</td></tr><tr><td>Performer</td><td> Clínica de Radiología San José</td></tr><tr><td>Identifier</td><td> <code>urn:oid:2.16.840.1.113883.4.6.1</code>/DR-2026-001234</td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>Note</b></td></tr><tr><td><a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-77777777-7777-7777-7777-777777777777"><span title="Codes:{http://snomed.info/sct 19829001}">Hallazgo radiológico de pulmones</span></a> (<span title="Codes:{http://snomed.info/sct 39607008}">Lung</span>)</td><td><span title="Codes:{http://snomed.info/sct 17621005}">Normal</span></td><td>Final, <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}">Normal</span></td><td><blockquote><div><p>Pulmones bien expandidos bilateralmente. Hilios pulmonares normales. Diafragmas regulares.</p> </div></blockquote></td></tr></table><div><p>Radiografía de tórax normal sin hallazgos patológicos.</p> </div><p><b>Coded Conclusions:</b></p><ul><li><span title="Codes:{http://snomed.info/sct 17621005}">Normal</span></li></ul></div> </text> <extension url="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid"> <extension url="uid"> <valueString value="1.2.840.113619.2.55.3.2830498741.123.1234567890.1"/> </extension> <extension url="seriesInstanceUid"> <valueString value="1.2.840.113619.2.55.3.2830498741.123.1234567890"/> </extension> <extension url="studyInstanceUid"> <valueString value="1.2.840.113619.2.55.3.2830498741.123"/> </extension> <extension url="accessUrl"> <valueUrl value="dicom-web://pacs.example.cr/studies/1.2.840.113619.2.55.3.2830498741.123/series/1.2.840.113619.2.55.3.2830498741.123.1234567890/instances/1.2.840.113619.2.55.3.2830498741.123.1234567890.1"/> </extension> <extension url="modality"> <valueCode value="CR"/> </extension> </extension> <extension url="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression"> <valueReference> <reference value="urn:uuid:77777777-7777-7777-7777-777777777777"/> </valueReference> </extension> <identifier> <system value="urn:oid:2.16.840.1.113883.4.6.1"/> <value value="DR-2026-001234"/> </identifier> <status value="final"/> <category> <coding> <system value="https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections"/> <code value="RAD"/> </coding> </category> <code> <coding> <system value="http://loinc.org"/> <code value="72134-0"/> </coding> <text value="Radiografía de Tórax"/> </code> <subject> <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/> </subject> <effectiveDateTime value="2026-01-20T09:15:00-06:00"/> <issued value="2026-01-20T10:30:00-06:00"/> <performer> <display value="Clínica de Radiología San José"/> </performer> <resultsInterpreter> <display value="Dr. Carlos López Martínez"/> </resultsInterpreter> <result> <reference value="urn:uuid:77777777-7777-7777-7777-777777777777"/> </result> <study> <reference value="urn:uuid:44444444-4444-4444-4444-444444444444"/> </study> <composition> <reference value="urn:uuid:11111111-1111-1111-1111-111111111111"/> </composition> <conclusion value="Radiografía de tórax normal sin hallazgos patológicos."/> <conclusionCode> <coding> <system value="http://snomed.info/sct"/> <code value="17621005"/> </coding> <text value="Normal"/> </conclusionCode> </DiagnosticReport> </resource> </entry> <entry> <fullUrl value="urn:uuid:33333333-3333-3333-3333-333333333333"/> <resource> <Patient> <id value="bundle-patient"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_bundle-patient"> </a><p class="res-header-id"><b>Generated Narrative: Patient bundle-patient</b></p><a name="bundle-patient"> </a><a name="hcbundle-patient"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</p><hr/></div> </text> <identifier> <system value="urn:oid:2.16.840.1.113883.18.4"/> <value value="123456789"/> </identifier> <name> <family value="Rodríguez García"/> <given value="María"/> </name> <gender value="female"/> <birthDate value="1975-05-15"/> </Patient> </resource> </entry> <entry> <fullUrl value="urn:uuid:44444444-4444-4444-4444-444444444444"/> <resource> <ImagingStudy> <id value="bundle-imaging-study"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="ImagingStudy_bundle-imaging-study"> </a><p class="res-header-id"><b>Generated Narrative: ImagingStudy bundle-imaging-study</b></p><a name="bundle-imaging-study"> </a><a name="hcbundle-imaging-study"> </a><p><b>identifier</b>: <a href="http://terminology.hl7.org/7.1.0/NamingSystem-dui.html" title="An OID issued under DICOM OID rules. DICOM OIDs are represented as plain OIDs, with a prefix of "urn:oid:". See https://www.dicomstandard.org/">DICOM Unique Id</a>/1.2.840.113619.2.55.3.2830498741.123</p><p><b>status</b>: Available</p><p><b>subject</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-33333333-3333-3333-3333-333333333333">María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</a></p><p><b>started</b>: 2026-01-20 09:00:00-0600</p><p><b>numberOfSeries</b>: 1</p><p><b>numberOfInstances</b>: 2</p></div> </text> <identifier> <system value="urn:dicom:uid"/> <value value="1.2.840.113619.2.55.3.2830498741.123"/> </identifier> <status value="available"/> <subject> <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/> </subject> <started value="2026-01-20T09:00:00-06:00"/> <numberOfSeries value="1"/> <numberOfInstances value="2"/> </ImagingStudy> </resource> </entry> <entry> <fullUrl value="urn:uuid:55555555-5555-5555-5555-555555555555"/> <resource> <ServiceRequest> <id value="bundle-service-request"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="ServiceRequest_bundle-service-request"> </a><p class="res-header-id"><b>Generated Narrative: ServiceRequest bundle-service-request</b></p><a name="bundle-service-request"> </a><a name="hcbundle-service-request"> </a><p><b>identifier</b>: <code>urn:oid:2.16.840.1.113883.4.6.1</code>/SR-2026-001</p><p><b>status</b>: Completed</p><p><b>intent</b>: Order</p><h3>Codes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Concept</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://loinc.org 71045-9}">I feel compassion for others in the difficulties they are facing in the past 7 days [FACIT]</span></td></tr></table><p><b>subject</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-33333333-3333-3333-3333-333333333333">María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</a></p><p><b>requester</b>: Centro de Salud Primario</p></div> </text> <identifier> <system value="urn:oid:2.16.840.1.113883.4.6.1"/> <value value="SR-2026-001"/> </identifier> <status value="completed"/> <intent value="order"/> <code> <concept> <coding> <system value="http://loinc.org"/> <code value="71045-9"/> </coding> </concept> </code> <subject> <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/> </subject> <requester> <display value="Centro de Salud Primario"/> </requester> </ServiceRequest> </resource> </entry> <entry> <fullUrl value="urn:uuid:66666666-6666-6666-6666-666666666666"/> <resource> <Procedure> <id value="bundle-procedure"/> <meta> <profile value="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-procedure-imaging-acquisition"/> </meta> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="Procedure_bundle-procedure"> </a><p class="res-header-id"><b>Generated Narrative: Procedure bundle-procedure</b></p><a name="bundle-procedure"> </a><a name="hcbundle-procedure"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-cr-procedure-imaging-acquisition.html">CR Procedure - Imaging Acquisition</a></p></div><p><b>identifier</b>: <code>urn:oid:2.16.840.1.113883.4.6.1</code>/PROC-2026-001</p><p><b>basedOn</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-55555555-5555-5555-5555-555555555555">ServiceRequest I feel compassion for others in the difficulties they are facing in the past 7 days [FACIT]</a></p><p><b>status</b>: Completed</p><p><b>category</b>: <span title="Codes:{http://snomed.info/sct 363679005}">Imaging</span></p><p><b>code</b>: <span title="Codes:{http://loinc.org 71045-9}">I feel compassion for others in the difficulties they are facing in the past 7 days [FACIT]</span></p><p><b>subject</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-33333333-3333-3333-3333-333333333333">María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</a></p><h3>Performers</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Actor</b></td></tr><tr><td style="display: none">*</td><td>Técnico en Radiología - Clínica San José</td></tr></table><p><b>report</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-22222222-2222-2222-2222-222222222222">Diagnostic Report for 'Informe de eventos de cáncer:{Configuración} :Punto temporal:Tipo:Documento:{Role}' for '->María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)'</a></p></div> </text> <identifier> <system value="urn:oid:2.16.840.1.113883.4.6.1"/> <value value="PROC-2026-001"/> </identifier> <basedOn> <reference value="urn:uuid:55555555-5555-5555-5555-555555555555"/> </basedOn> <status value="completed"/> <category> <coding> <system value="http://snomed.info/sct"/> <code value="363679005"/> </coding> </category> <code> <coding> <system value="http://loinc.org"/> <code value="71045-9"/> </coding> </code> <subject> <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/> </subject> <performer> <actor> <display value="Técnico en Radiología - Clínica San José"/> </actor> </performer> <report> <reference value="urn:uuid:22222222-2222-2222-2222-222222222222"/> </report> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:77777777-7777-7777-7777-777777777777"/> <resource> <Observation> <id value="bundle-observation"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_bundle-observation"> </a><p class="res-header-id"><b>Generated Narrative: Observation bundle-observation</b></p><a name="bundle-observation"> </a><a name="hcbundle-observation"> </a><p><b>status</b>: Final</p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 19829001}">Hallazgo radiológico de pulmones</span></p><p><b>subject</b>: <a href="Bundle-bundle-imaging-report-with-dicom-example.html#urn-uuid-33333333-3333-3333-3333-333333333333">María Rodríguez García Female, DoB: 1975-05-15 ( urn:oid:2.16.840.1.113883.18.4#123456789)</a></p><p><b>effective</b>: 2026-01-20 09:15:00-0600</p><p><b>performer</b>: Dr. Carlos López Martínez</p><p><b>value</b>: <span title="Codes:{http://snomed.info/sct 17621005}">Normal</span></p><p><b>interpretation</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}">Normal</span></p><p><b>note</b>: </p><blockquote><div><p>Pulmones bien expandidos bilateralmente. Hilios pulmonares normales. Diafragmas regulares.</p> </div></blockquote><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 39607008}">Lung</span></p></div> </text> <status value="final"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="19829001"/> </coding> <text value="Hallazgo radiológico de pulmones"/> </code> <subject> <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/> </subject> <effectiveDateTime value="2026-01-20T09:15:00-06:00"/> <performer> <display value="Dr. Carlos López Martínez"/> </performer> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="17621005"/> </coding> <text value="Normal"/> </valueCodeableConcept> <interpretation> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> <code value="N"/> </coding> </interpretation> <note> <text value="Pulmones bien expandidos bilateralmente. Hilios pulmonares normales. Diafragmas regulares."/> </note> <bodySite> <coding> <system value="http://snomed.info/sct"/> <code value="39607008"/> </coding> </bodySite> </Observation> </resource> </entry> </Bundle>