HL7 FHIR Costa Rica - Reportes de Imágenes Médicas
0.0.1-draft - ci-build

HL7 FHIR Costa Rica - Reportes de Imágenes Médicas, published by Iniciativa HL7 Costa Rica. This guide is not an authorized publication; it is the continuous build for version 0.0.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cr/imaging-report/ and changes regularly. See the Directory of published versions

## : Bundle Completo de Reporte de Imagen - XML Representation

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    <Bundle xmlns="http://hl7.org/fhir">
      <id value="bundle-imaging-report-with-dicom-example"/>
      <meta>
        <profile
                 value="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-imaging-report-bundle"/>
      </meta>
      <identifier>
        <system value="urn:oid:2.16.840.1.113883.4.6.1"/>
        <value value="DR-2026-BUNDLE-001"/>
      </identifier>
      <type value="document"/>
      <timestamp value="2026-01-20T10:30:00-06:00"/>
      <entry>
        <fullUrl value="urn:uuid:11111111-1111-1111-1111-111111111111"/>
        <resource>
          <Composition>
            <id value="bundle-composition-imaging"/>
            <meta>
              <profile
                       value="https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-composition-imaging-report"/>
            </meta>
            <text>
              <status value="generated"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Composition_bundle-composition-imaging"> </a><p class="res-header-id"><b>Generated Narrative: Composition bundle-composition-imaging</b></p><a name="bundle-composition-imaging"> </a><a name="hcbundle-composition-imaging"> </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-composition-imaging-report.html">CR Composition - Imaging Report</a></p></div><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 72134-0}">Informe de eventos de cáncer:{Configuración} :Punto temporal:Tipo:Documento:{Role}</span></p><p><b>date</b>: 2026-01-20 10:30:00-0600</p><p><b>author</b>: Dr. Carlos López Martínez, Radiólogo</p><p><b>title</b>: Radiografía de Tórax - Reporte Final</p></div>
            </text>
            <status value="final"/>
            <type>
              <coding>
                <system value="http://loinc.org"/>
                <code value="72134-0"/>
              </coding>
            </type>
            <subject>
              <reference value="urn:uuid:33333333-3333-3333-3333-333333333333"/>
            </subject>
            <date value="2026-01-20T10:30:00-06:00"/>
            <author>
              <display value="Dr. Carlos López Martínez, Radiólogo"/>
            </author>
            <title value="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 &quot;urn:oid:&quot;. 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 '-&gt;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>