# Ejemplo de Reporte Radiológico X-Ray con Acceso DICOM - HL7 FHIR Costa Rica - Reportes de Imágenes Médicas v0.0.1-draft

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Ejemplo de Reporte Radiológico X-Ray con Acceso DICOM**

## Example DiagnosticReport: Ejemplo de Reporte Radiológico X-Ray con Acceso DICOM

| |
| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R5/versions.html#std-process) |

Profile: [CR Diagnostic Report](StructureDefinition-cr-diagnostic-report.md)

## Radiografía de Tórax (Radiology) 

| | |
| :--- | :--- |
| Subject | Unable to get Patient Details |
| When For | 2026-01-20 09:15:00-0600 |
| Reported | 2026-01-20 10:30:00-0600 |
| Performer | Clínica de Radiología San José |
| Identifier | `urn:oid:2.16.840.1.113883.4.6.1`/DR-2026-001234 |

**Report Details**

* **Code**: [Hallazgo radiológico de pulmones](Observation-observation-xray-lung-finding.md)(Pulmones)
  * **Value**: Normal
  * **Flags**: Final,Normal
  * **Note**: > Pulmones bien expandidos bilateralmente. Hilios pulmonares normales.

Radiografía de tórax posteroanterior: Pulmones bien expandidos bilateralmente. No hay opacidades localizadas ni consolidaciones. Corazón de tamaño normal. Mediastino dentro de los límites normales. Diafragmas regulares. Sin neumotórax. Hilios pulmonares normales.

**Coded Conclusions:**

* Normal



## Resource Content

```json
{
  "resourceType" : "DiagnosticReport",
  "id" : "diagnostic-report-xray-with-dicom-example",
  "meta" : {
    "profile" : ["https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-diagnostic-report"]
  },
  "extension" : [{
    "extension" : [{
      "url" : "uid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123.1234567890.1"
    },
    {
      "url" : "seriesInstanceUid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123.1234567890"
    },
    {
      "url" : "studyInstanceUid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123"
    },
    {
      "url" : "accessUrl",
      "valueUrl" : "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"
    },
    {
      "url" : "modality",
      "valueCode" : "CR"
    }],
    "url" : "https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid"
  },
  {
    "extension" : [{
      "url" : "uid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123.1234567890.2"
    },
    {
      "url" : "seriesInstanceUid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123.1234567890"
    },
    {
      "url" : "studyInstanceUid",
      "valueString" : "1.2.840.113619.2.55.3.2830498741.123"
    },
    {
      "url" : "accessUrl",
      "valueUrl" : "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/1.2.840.113619.2.55.3.2830498741.123.1234567890.2"
    },
    {
      "url" : "modality",
      "valueCode" : "CR"
    }],
    "url" : "https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid"
  }],
  "identifier" : [{
    "system" : "urn:oid:2.16.840.1.113883.4.6.1",
    "value" : "DR-2026-001234"
  }],
  "status" : "final",
  "category" : [{
    "coding" : [{
      "system" : "https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections",
      "code" : "RAD",
      "display" : "Radiology"
    }]
  }],
  "code" : {
    "coding" : [{
      "system" : "https://hl7.or.cr/fhir/terminology/CodeSystem/cr-report-codes",
      "code" : "CXR",
      "display" : "Radiografía de Tórax (Rayos X)"
    }],
    "text" : "Radiografía de Tórax"
  },
  "subject" : {
    "display" : "María Rodríguez García"
  },
  "effectiveDateTime" : "2026-01-20T09:15:00-06:00",
  "issued" : "2026-01-20T10:30:00-06:00",
  "performer" : [{
    "display" : "Clínica de Radiología San José"
  }],
  "result" : [{
    "reference" : "Observation/observation-xray-lung-finding"
  }],
  "composition" : {
    "reference" : "Composition/composition-xray-example"
  },
  "conclusion" : "Radiografía de tórax posteroanterior: Pulmones bien expandidos bilateralmente. No hay opacidades localizadas ni consolidaciones. Corazón de tamaño normal. Mediastino dentro de los límites normales. Diafragmas regulares. Sin neumotórax. Hilios pulmonares normales.",
  "conclusionCode" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "17621005",
      "display" : "Normal"
    }]
  }]
}

```
