HL7 Czech Imaging Report IG
0.1.0-ballot - ci-build Czechia flag

HL7 Czech Imaging Report IG, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.1.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/img/ and changes regularly. See the Directory of published versions

Logical Model: LogEnReportOfImagingMethodCz - Detailed Descriptions

Page standards status: Draft Maturity Level: 1

Definitions for the ReportOfImagingMethod logical model.

Guidance on how to interpret the contents of this table can be foundhere

0. ReportOfImagingMethod
Definition

Imaging Report - Imaging Report report of imaging method - A.2.4

ShortA.2.4 - Report of imaging method
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. ReportOfImagingMethod.typeOfModality
Definition

The type of modality that was used.

  • Preferred system(s): DICOM [ModalityCodelist]
ShortA.2.4.1 - Modality type
Control0..*
TypeCodeableConcept
4. ReportOfImagingMethod.typeOfImagingMethod
Definition

Display method type.

  • Preferred system(s): Valueset ČRK (ERTN)
  • Preferred system(s): LOINC Imaging Document Codes
ShortA.2.4.2 - Type of imaging method
Control1..*
TypeCodeableConcept
6. ReportOfImagingMethod.reason
Definition

Reason (indication)

ShortA.2.4.3 - Reason (indication)
Control0..*
TypeBase
8. ReportOfImagingMethod.reason.description
Definition

Description of the clinical condition, stating the reason why the imaging method was ordered (indicated). Example: "Cough lasting 3 months".

ShortA.2.4.3.1 - Description of the reason
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. ReportOfImagingMethod.reason.classification
Definition

Reason code for performing the display method.

  • Preferred system(s): SNOMED CT [ReasonCodelist]
ShortA.2.4.3.2 - Classification of reason
Control0..*
TypeCodeableConcept
12. ReportOfImagingMethod.clinicalQuestion
Definition

The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.'

ShortA.2.4.4 - A clinical question
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
14. ReportOfImagingMethod.partOfBody
Definition

The body part that is the subject of an examination or procedure. At least one of the Body Part Code or Description elements must be present.

ShortA.2.4.5 - Body part
Control0..*
TypeBase
16. ReportOfImagingMethod.partOfBody.code
Definition

Body part classification code, location on/in the body.

  • Preferred system(s): SNOMED CT [BodyLocation|LocationICT-O-3]
ShortA.2.4.5.1 - Body part code
Control0..1
TypeCodeableConcept
18. ReportOfImagingMethod.partOfBody.laterality
Definition

Sideness, if meaningful. (Location on the side of the body, if needed to distinguish from a similar location on the other side of the body. If laterality is present, body location must also be present.)

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.5.2 - Laterality of body part
Control0..1
TypeCodeableConcept
20. ReportOfImagingMethod.partOfBody.description
Definition

Human-readable description of the location on the body.

ShortA.2.4.5.3 - Body part description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. ReportOfImagingMethod.procedure
Definition

Description of the procedure expressed by code and/or text description. (E.g. used MR sequences, image projection...)

ShortA.2.4.6 - Performance (procedure)
Control0..*
TypeBase
24. ReportOfImagingMethod.procedure.reason
Definition

The reason for performing the procedure in a formalized or textual description.

ShortA.2.4.6.1 - Reason for performance
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
26. ReportOfImagingMethod.procedure.start
Definition

(Required) start date (and possibly start time) of the performance. It is permitted to provide a 'vague' date, e.g. only a year.

ShortA.2.4.6.2 - Start of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. ReportOfImagingMethod.procedure.end
Definition

The end date (and possibly the end time) of the service. It is allowed to specify an 'indefinite' date, e.g. only a year. The end date element is used only for services that last a certain time and then are always used. If the service is still ongoing, the value is left blank. For immediate or very short-term services, the element is omitted.

ShortA.2.4.6.3 - End of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. ReportOfImagingMethod.procedure.performedBy
Definition

The healthcare professional and/or provider who performed the procedure.

ShortA.2.4.6.4 - Performed by
Control0..*
TypeHumanName
32. ReportOfImagingMethod.procedure.recordedBy
Definition

The healthcare professional who created the performance record and is responsible for its content.

ShortA.2.4.6.5 - Recorded by
Control0..1
TypeHumanName
34. ReportOfImagingMethod.procedure.place
Definition

Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination.

ShortA.2.4.6.6 - Place of performance
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
36. ReportOfImagingMethod.procedure.anatomicalFocus
Definition

The anatomical site where the procedure is targeted. Must contain at least one of the elements, either a code and/or a human-readable description of the site on/in the body.

ShortA.2.4.6.7 - Anatomical focus of performance
Control0..1
TypeBase
38. ReportOfImagingMethod.procedure.anatomicalFocus.code
Definition

The place on/in the body where the performance is focused.

  • Preferred system(s): SNOMED CT < 123037004 | Body structure
  • Preferred system(s): ICD-O-3 International Classification of Diseases for Oncology, version 3 (Topography codes)
ShortA.2.4.6.7.1 - Body location code
Control0..1
TypeCodeableConcept
40. ReportOfImagingMethod.procedure.anatomicalFocus.laterality
Definition

The location on the side of the body, if it is necessary to distinguish it from a similar location on the other side of the body. If laterality is present, the location of the location on/in the body must also be present.

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.6.7.2 - Laterality of the body location
Control0..1
TypeCodeableConcept
42. ReportOfImagingMethod.procedure.anatomicalFocus.description
Definition

A human-readable description of the location on/in the body where the performance is targeted.

ShortA.2.4.6.7.3 - Description of the location on/in the body
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. ReportOfImagingMethod.procedure.complication
Definition

Any complications that occurred during or immediately after the procedure. These are usually tracked separately from the notes, which usually describe the procedure itself, not 'post-procedure' problems.

ShortA.2.4.6.8 - Complications during the procedure
Control0..*
TypeBase
46. ReportOfImagingMethod.procedure.complication.code
Definition

Indicating complications during or immediately after the procedure using a coding system.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.8.1 - Complications formalized
Control0..*
TypeCodeableConcept
48. ReportOfImagingMethod.procedure.complication.description
Definition

Textual (narrative) description of complications during or immediately after the procedure.

ShortA.2.4.6.8.2 - Description of complications
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. ReportOfImagingMethod.procedure.comment
Definition

Notes and comments on the performance (procedure).

ShortA.2.4.6.9 - Comment on the performance (procedure)
Control0..*
TypeBase
52. ReportOfImagingMethod.procedure.comment.author
Definition

Author of the comment.

ShortA.2.4.6.9.1 - Author of the comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. ReportOfImagingMethod.procedure.comment.text
Definition

Plain or formatted text content of the comment.

ShortA.2.4.6.9.2 - Text of the comment
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
56. ReportOfImagingMethod.procedure.comment.dateTime
Definition

When the comment was written. This element must be included if the information cannot be inferred from the context (e.g. from visit information, etc.).

ShortA.2.4.6.9.3 - Date and time of the comment
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
58. ReportOfImagingMethod.procedure.usedDevice
Definition

A medical device used during a procedure.

ShortA.2.4.6.10 - Used medical device
Control0..*
TypeBase
60. ReportOfImagingMethod.procedure.usedDevice.name
Definition

The brand name of the device or software.

ShortA.2.4.6.10.1 - Name of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
62. ReportOfImagingMethod.procedure.usedDevice.model
Definition

Device model or software version.

ShortA.2.4.6.10.2 - Medical device model
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
64. ReportOfImagingMethod.procedure.usedDevice.iden
Definition

Unique identifiers assigned to a device by the manufacturer, other organization, or owner, such as a serial number. A commonly used coding system is the GTIN.

ShortA.2.4.6.10.3 - Medical device ID
Control0..*
TypeIdentifier
66. ReportOfImagingMethod.procedure.usedDevice.type
Definition

Product type code.

  • Preferred system(s): SNOMED CT
  • Preferred system(s): EMDN
ShortA.2.4.6.10.4 - Type of medical device
Control0..1
TypeCodeableConcept
68. ReportOfImagingMethod.procedure.usedDevice.description
Definition

Additional text description/specification of the device.

ShortA.2.4.6.10.5 - Description of the medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
70. ReportOfImagingMethod.procedure.usedDevice.manufacturer
Definition

The name of the device or software manufacturer.

ShortA.2.4.6.10.6 - Manufacturer of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
72. ReportOfImagingMethod.procedure.usedDevice.udi
Definition

UDI of the medical device placed on the label or packaging of the device.

ShortA.2.4.6.10.7 - UDI of the medical device
Control0..1
TypeIdentifier
74. ReportOfImagingMethod.procedure.category
Definition

The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.

  • Preferred system(s): SNOMED CT [ProcedureCategoryCodelist]
ShortA.2.4.6.11 - Performance category (procedures)
Control0..*
TypeCodeableConcept
76. ReportOfImagingMethod.procedure.code
Definition

Code, or possibly name of the procedure.

  • Preferred system(s): SNOMED CT [ProcedureCodelist]
ShortA.2.4.6.12 - Performance (procedure)
Control1..1
TypeCodeableConcept
78. ReportOfImagingMethod.procedure.achievement
Definition

Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.13 - Achieving a result
Control0..1
TypeCodeableConcept
80. ReportOfImagingMethod.procedure.illnessCode
Definition

A detailed description or reference to information about the patient's health condition/health problem that is the reason for performing the procedure.

  • Preferred system(s): MKN-10
  • Preferred system(s): Orphacode
ShortA.2.4.6.14 - Illness - reason for the procedure
Control0..*
TypeCodeableConcept
82. ReportOfImagingMethod.procedure.relatedDevice
Definition

A medical device that is implanted, removed, or otherwise manipulated (calibration, battery replacement, prosthesis insertion, wound suction application, etc.) as a core part of a procedure.

ShortA.2.4.6.15 - Resource related
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
84. ReportOfImagingMethod.medication
Definition

Any substance administered in connection with a given procedure (typically a contrast agent, but it can also be another type of drug, e.g. a drug to reduce intestinal motility).

ShortA.2.4.7 - Medication
Control0..*
TypeBase
86. ReportOfImagingMethod.medication.name
Definition

The medication administered in connection with the examination (typically a contrast agent, but it can also be another type of medication, e.g. a medicine to reduce bowel motility). Usually these are medications. Food, blood products, devices and dressings do not strictly fall into the category of medications, but may also be recorded.

ShortA.2.4.7.1 - Administered medicinal product
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
88. ReportOfImagingMethod.medication.dosage
Definition

The dose of the medicinal product administered.

ShortA.2.4.7.2 - Dosage
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
90. ReportOfImagingMethod.medication.routeOfAdministration
Definition

The way in which the patient came into contact with the active substance or the way in which the active substance was administered.

  • Preferred system(s): SNOMED CT: <284009009 | Route of administration value
ShortA.2.4.7.3 - The route of administration of the active substance
Control0..1
TypeCodeableConcept
92. ReportOfImagingMethod.medication.dosingDevice
Definition

A device used to administer medication to a patient. For example, a specific infusion pump.

ShortA.2.4.7.4 - Dosing device
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
94. ReportOfImagingMethod.medication.batchNumber
Definition

Information related to the packaged products. The assigned batch number of the specified product. When this specific batch of the product will expire.

ShortA.2.4.7.5 - Batch number
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. ReportOfImagingMethod.medication.dateTimeStart
Definition

Start Date: This is the time when the administration was started.

ShortA.2.4.7.6 - Start date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
98. ReportOfImagingMethod.medication.dateTimeEnd
Definition

End Date: The time the administration period ended (or was supposed to end).

ShortA.2.4.7.7 - End date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
100. ReportOfImagingMethod.medication.administrator
Definition

The healthcare professional who administered the medication.

ShortA.2.4.7.8 - Administrator
Control0..1
TypeHumanName
102. ReportOfImagingMethod.medication.reasonForSubmission
Definition

Reason for administering the medication. The patient's condition that was the reason for administering the medication or the observation that supports why the medication was administered.

ShortA.2.4.7.9 - Reason for submission
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
104. ReportOfImagingMethod.medication.comment
Definition

Comments on the administration of the medicinal product.

ShortA.2.4.7.10 - Comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
106. ReportOfImagingMethod.medication.dateTimeOfEntry
Definition

The date on which this information about the administration of the medicinal product is entered.

ShortA.2.4.7.11 - Entry date and time
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
108. ReportOfImagingMethod.adverseReaction
Definition

Adverse reactions related to medication or procedure.

ShortA.2.4.8 - Adverse reaction
Control0..*
TypeBase
110. ReportOfImagingMethod.adverseReaction.reaction
Definition

Reactions that are a manifestation of allergy or intolerance. These are events that may occur or have occurred in the past as a reaction to the cause of the allergy or intolerance.

  • Preferred system(s): SNOMED CT
ShortA.2.4.8.1 - Allergy code
Control1..*
TypeCodeableConcept
112. ReportOfImagingMethod.adverseReaction.seriousness
Definition

Severity of reaction due to medication or exposure.

  • Preferred system(s): SNOMED CT 'Mírná', 'Středně těžká', 'Těžká'
ShortA.2.4.8.2 - Allergy manifestation
Control0..1
TypeCodeableConcept
114. ReportOfImagingMethod.adverseReaction.dateTime
Definition

The date and time the reaction occurred. It can also be just a date or a partial date if the exact date is not known.

ShortA.2.4.8.3 - Alergy date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
116. ReportOfImagingMethod.adverseReaction.allergyDescription
Definition

Text description of the reaction as a whole.

ShortA.2.4.8.4 - Alergy description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
118. ReportOfImagingMethod.resultOfImagingMethod
Definition

Section Reports from imaging methods containing narrative result and optionally formalized result using coding systems

ShortA.2.4.9 - Result of the imaging method
Control1..1
TypeBase
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText
Definition

Summary textual (narrative) description of the results of imaging methods

ShortA.2.4.9.1 - Narrative text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText
Definition

Formalized structured result of the imaging method

ShortA.2.4.9.2 - Formalized text
Control0..*
TypeBase
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note
Definition

A note about the result. It should have an author and a timestamp.

ShortA.2.4.9.2.1 - Note
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
126. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationGroup
Definition

This is a grouping mechanism. An observation can be part of a group of observations (for example, a test panel) that are ordered, performed, or reported together.

ShortA.2.4.9.2.2 - Observation (measurement) group
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
128. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationComponent
Definition

Some observations have multiple sub-observations. These component observations are expressed as separate pairs of value codes that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurements and multiple component observations for genetic observations.

ShortA.2.4.9.2.3 - Observation (measurement) component
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
130. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.specimen
Definition

Information about the specimen used in the observation.

ShortA.2.4.9.2.4 - Specimen
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
132. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.referenceRanges
Definition

Information on the reference range relevant to the target population.

ShortA.2.4.9.2.5 - Reference ranges
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
134. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.reasonForAbsence
Definition

The reason why the expected value of the observation is missing.

ShortA.2.4.9.2.6 - The reason for the absence of a value
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
136. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationValue
Definition

The resulting value of the observation. There can be different types of values, either numeric, textual, coded, or raw data may be present.

ShortA.2.4.9.2.7 - Observation value (measurement)
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
138. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.interpretation
Definition

Interpretation of the result of observation (measurement).

ShortA.2.4.9.2.8 - Interpretation of the result
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
140. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationMethod
Definition

Information about the method, principle, or mechanism of observation.

ShortA.2.4.9.2.9 - Observation (measurement) method
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
142. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.derivedFrom
Definition

The source from which this observation value is derived. For example, fetal measurements based on an ultrasound image.

ShortA.2.4.9.2.10 - Derived from
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart
Definition

Specification of the observed body part.

ShortA.2.4.9.2.11 - Observed body part
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
146. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationStatus
Definition

The status of the observation as final, preliminary, or changed.

ShortA.2.4.9.2.12 - Observation status
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
148. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCode
Definition

Coded information about the type of observation.

  • Preferred system(s): SNOMED CT
ShortA.2.4.9.2.13 - Observation code
Control1..1
TypeCodeableConcept
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory
Definition

Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc.

ShortA.2.4.9.2.14 - Observation category
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
152. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationEquipment
Definition

The device used to make an observation and obtain a result.

ShortA.2.4.9.2.15 - Observation equipment used
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
154. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.dateTimeObservation
Definition

Date and time or period of observation.

ShortA.2.4.9.2.16 - Observation date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
156. ReportOfImagingMethod.resultOfImagingMethod.dateTimeResult
Definition

The date and time the observation was made available, usually after verification.

ShortA.2.4.9.3 - Result release date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
158. ReportOfImagingMethod.resultOfImagingMethod.author
Definition

The healthcare professional and/or healthcare provider organization where or by whom the observation was authorized.

ShortA.2.4.9.4 - Result author
Control0..1
TypeHumanName
160. ReportOfImagingMethod.conclusion
Definition

The conclusion summarizes the most important findings and/or diagnoses that were made based on the imaging findings (and possibly other clinical information). This section may include a coded assessment, such as BI-RADS categories or equivalent.

ShortA.2.4.10 - Conclusion
Control0..1
TypeBase
162. ReportOfImagingMethod.conclusion.text
Definition

Narrative text description of the clinical conclusion.

ShortA.2.4.10.1 - Conclusion text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
164. ReportOfImagingMethod.conclusion.code
Definition

Coded clinical findings - conditions or observations (one or the other). Commonly used staging systems (TNM, Bi-Rads, Li-Rads, etc.) can be expressed as a condition with staging (typically TNM, but also others) or as coded observations (Bi-Rads, Li-Rads, etc.).

  • Preferred system(s): TNM, Bi-Rads, Li-Rads
ShortA.2.4.10.2 - Coded conclusion
Control0..1
TypeCodeableConcept
166. ReportOfImagingMethod.recommendation
Definition

This section contains recommendations for follow-up examinations or procedures that resulted from the results and/or conclusions. The structured part of this item is identical to the item of the same name in the discharge report.

ShortA.2.4.11 - Recommendation
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
168. ReportOfImagingMethod.textPartsOfDocument
Definition

Summary text (narrative) parts of the document.

ShortA.2.4.12 - Text parts of the document
Control0..1
TypeBase
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport
Definition

The complete examination report, as issued.

ShortA.2.4.12.1 - Complete examination report
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
172. ReportOfImagingMethod.textPartsOfDocument.comments
Definition

Comments, such as textual interpretations or recommendations, that are part of the examination report.

ShortA.2.4.12.2 - Comments, interpretations and recommendations
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. ReportOfImagingMethod
Definition

Imaging Report - Imaging Report report of imaging method - A.2.4

ShortA.2.4 - Report of imaging method
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. ReportOfImagingMethod.typeOfModality
Definition

The type of modality that was used.

  • Preferred system(s): DICOM [ModalityCodelist]
ShortA.2.4.1 - Modality type
Control0..*
TypeCodeableConcept
4. ReportOfImagingMethod.typeOfImagingMethod
Definition

Display method type.

  • Preferred system(s): Valueset ČRK (ERTN)
  • Preferred system(s): LOINC Imaging Document Codes
ShortA.2.4.2 - Type of imaging method
Control1..*
TypeCodeableConcept
6. ReportOfImagingMethod.reason
Definition

Reason (indication)

ShortA.2.4.3 - Reason (indication)
Control0..*
TypeBase
8. ReportOfImagingMethod.reason.description
Definition

Description of the clinical condition, stating the reason why the imaging method was ordered (indicated). Example: "Cough lasting 3 months".

ShortA.2.4.3.1 - Description of the reason
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. ReportOfImagingMethod.reason.classification
Definition

Reason code for performing the display method.

  • Preferred system(s): SNOMED CT [ReasonCodelist]
ShortA.2.4.3.2 - Classification of reason
Control0..*
TypeCodeableConcept
12. ReportOfImagingMethod.clinicalQuestion
Definition

The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.'

ShortA.2.4.4 - A clinical question
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
14. ReportOfImagingMethod.partOfBody
Definition

The body part that is the subject of an examination or procedure. At least one of the Body Part Code or Description elements must be present.

ShortA.2.4.5 - Body part
Control0..*
TypeBase
16. ReportOfImagingMethod.partOfBody.code
Definition

Body part classification code, location on/in the body.

  • Preferred system(s): SNOMED CT [BodyLocation|LocationICT-O-3]
ShortA.2.4.5.1 - Body part code
Control0..1
TypeCodeableConcept
18. ReportOfImagingMethod.partOfBody.laterality
Definition

Sideness, if meaningful. (Location on the side of the body, if needed to distinguish from a similar location on the other side of the body. If laterality is present, body location must also be present.)

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.5.2 - Laterality of body part
Control0..1
TypeCodeableConcept
20. ReportOfImagingMethod.partOfBody.description
Definition

Human-readable description of the location on the body.

ShortA.2.4.5.3 - Body part description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. ReportOfImagingMethod.procedure
Definition

Description of the procedure expressed by code and/or text description. (E.g. used MR sequences, image projection...)

ShortA.2.4.6 - Performance (procedure)
Control0..*
TypeBase
24. ReportOfImagingMethod.procedure.reason
Definition

The reason for performing the procedure in a formalized or textual description.

ShortA.2.4.6.1 - Reason for performance
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
26. ReportOfImagingMethod.procedure.start
Definition

(Required) start date (and possibly start time) of the performance. It is permitted to provide a 'vague' date, e.g. only a year.

ShortA.2.4.6.2 - Start of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. ReportOfImagingMethod.procedure.end
Definition

The end date (and possibly the end time) of the service. It is allowed to specify an 'indefinite' date, e.g. only a year. The end date element is used only for services that last a certain time and then are always used. If the service is still ongoing, the value is left blank. For immediate or very short-term services, the element is omitted.

ShortA.2.4.6.3 - End of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. ReportOfImagingMethod.procedure.performedBy
Definition

The healthcare professional and/or provider who performed the procedure.

ShortA.2.4.6.4 - Performed by
Control0..*
TypeHumanName
32. ReportOfImagingMethod.procedure.recordedBy
Definition

The healthcare professional who created the performance record and is responsible for its content.

ShortA.2.4.6.5 - Recorded by
Control0..1
TypeHumanName
34. ReportOfImagingMethod.procedure.place
Definition

Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination.

ShortA.2.4.6.6 - Place of performance
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
36. ReportOfImagingMethod.procedure.anatomicalFocus
Definition

The anatomical site where the procedure is targeted. Must contain at least one of the elements, either a code and/or a human-readable description of the site on/in the body.

ShortA.2.4.6.7 - Anatomical focus of performance
Control0..1
TypeBase
38. ReportOfImagingMethod.procedure.anatomicalFocus.code
Definition

The place on/in the body where the performance is focused.

  • Preferred system(s): SNOMED CT < 123037004 | Body structure
  • Preferred system(s): ICD-O-3 International Classification of Diseases for Oncology, version 3 (Topography codes)
ShortA.2.4.6.7.1 - Body location code
Control0..1
TypeCodeableConcept
40. ReportOfImagingMethod.procedure.anatomicalFocus.laterality
Definition

The location on the side of the body, if it is necessary to distinguish it from a similar location on the other side of the body. If laterality is present, the location of the location on/in the body must also be present.

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.6.7.2 - Laterality of the body location
Control0..1
TypeCodeableConcept
42. ReportOfImagingMethod.procedure.anatomicalFocus.description
Definition

A human-readable description of the location on/in the body where the performance is targeted.

ShortA.2.4.6.7.3 - Description of the location on/in the body
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. ReportOfImagingMethod.procedure.complication
Definition

Any complications that occurred during or immediately after the procedure. These are usually tracked separately from the notes, which usually describe the procedure itself, not 'post-procedure' problems.

ShortA.2.4.6.8 - Complications during the procedure
Control0..*
TypeBase
46. ReportOfImagingMethod.procedure.complication.code
Definition

Indicating complications during or immediately after the procedure using a coding system.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.8.1 - Complications formalized
Control0..*
TypeCodeableConcept
48. ReportOfImagingMethod.procedure.complication.description
Definition

Textual (narrative) description of complications during or immediately after the procedure.

ShortA.2.4.6.8.2 - Description of complications
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. ReportOfImagingMethod.procedure.comment
Definition

Notes and comments on the performance (procedure).

ShortA.2.4.6.9 - Comment on the performance (procedure)
Control0..*
TypeBase
52. ReportOfImagingMethod.procedure.comment.author
Definition

Author of the comment.

ShortA.2.4.6.9.1 - Author of the comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. ReportOfImagingMethod.procedure.comment.text
Definition

Plain or formatted text content of the comment.

ShortA.2.4.6.9.2 - Text of the comment
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
56. ReportOfImagingMethod.procedure.comment.dateTime
Definition

When the comment was written. This element must be included if the information cannot be inferred from the context (e.g. from visit information, etc.).

ShortA.2.4.6.9.3 - Date and time of the comment
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
58. ReportOfImagingMethod.procedure.usedDevice
Definition

A medical device used during a procedure.

ShortA.2.4.6.10 - Used medical device
Control0..*
TypeBase
60. ReportOfImagingMethod.procedure.usedDevice.name
Definition

The brand name of the device or software.

ShortA.2.4.6.10.1 - Name of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
62. ReportOfImagingMethod.procedure.usedDevice.model
Definition

Device model or software version.

ShortA.2.4.6.10.2 - Medical device model
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
64. ReportOfImagingMethod.procedure.usedDevice.iden
Definition

Unique identifiers assigned to a device by the manufacturer, other organization, or owner, such as a serial number. A commonly used coding system is the GTIN.

ShortA.2.4.6.10.3 - Medical device ID
Control0..*
TypeIdentifier
66. ReportOfImagingMethod.procedure.usedDevice.type
Definition

Product type code.

  • Preferred system(s): SNOMED CT
  • Preferred system(s): EMDN
ShortA.2.4.6.10.4 - Type of medical device
Control0..1
TypeCodeableConcept
68. ReportOfImagingMethod.procedure.usedDevice.description
Definition

Additional text description/specification of the device.

ShortA.2.4.6.10.5 - Description of the medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
70. ReportOfImagingMethod.procedure.usedDevice.manufacturer
Definition

The name of the device or software manufacturer.

ShortA.2.4.6.10.6 - Manufacturer of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
72. ReportOfImagingMethod.procedure.usedDevice.udi
Definition

UDI of the medical device placed on the label or packaging of the device.

ShortA.2.4.6.10.7 - UDI of the medical device
Control0..1
TypeIdentifier
74. ReportOfImagingMethod.procedure.category
Definition

The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.

  • Preferred system(s): SNOMED CT [ProcedureCategoryCodelist]
ShortA.2.4.6.11 - Performance category (procedures)
Control0..*
TypeCodeableConcept
76. ReportOfImagingMethod.procedure.code
Definition

Code, or possibly name of the procedure.

  • Preferred system(s): SNOMED CT [ProcedureCodelist]
ShortA.2.4.6.12 - Performance (procedure)
Control1..1
TypeCodeableConcept
78. ReportOfImagingMethod.procedure.achievement
Definition

Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.13 - Achieving a result
Control0..1
TypeCodeableConcept
80. ReportOfImagingMethod.procedure.illnessCode
Definition

A detailed description or reference to information about the patient's health condition/health problem that is the reason for performing the procedure.

  • Preferred system(s): MKN-10
  • Preferred system(s): Orphacode
ShortA.2.4.6.14 - Illness - reason for the procedure
Control0..*
TypeCodeableConcept
82. ReportOfImagingMethod.procedure.relatedDevice
Definition

A medical device that is implanted, removed, or otherwise manipulated (calibration, battery replacement, prosthesis insertion, wound suction application, etc.) as a core part of a procedure.

ShortA.2.4.6.15 - Resource related
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
84. ReportOfImagingMethod.medication
Definition

Any substance administered in connection with a given procedure (typically a contrast agent, but it can also be another type of drug, e.g. a drug to reduce intestinal motility).

ShortA.2.4.7 - Medication
Control0..*
TypeBase
86. ReportOfImagingMethod.medication.name
Definition

The medication administered in connection with the examination (typically a contrast agent, but it can also be another type of medication, e.g. a medicine to reduce bowel motility). Usually these are medications. Food, blood products, devices and dressings do not strictly fall into the category of medications, but may also be recorded.

ShortA.2.4.7.1 - Administered medicinal product
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
88. ReportOfImagingMethod.medication.dosage
Definition

The dose of the medicinal product administered.

ShortA.2.4.7.2 - Dosage
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
90. ReportOfImagingMethod.medication.routeOfAdministration
Definition

The way in which the patient came into contact with the active substance or the way in which the active substance was administered.

  • Preferred system(s): SNOMED CT: <284009009 | Route of administration value
ShortA.2.4.7.3 - The route of administration of the active substance
Control0..1
TypeCodeableConcept
92. ReportOfImagingMethod.medication.dosingDevice
Definition

A device used to administer medication to a patient. For example, a specific infusion pump.

ShortA.2.4.7.4 - Dosing device
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
94. ReportOfImagingMethod.medication.batchNumber
Definition

Information related to the packaged products. The assigned batch number of the specified product. When this specific batch of the product will expire.

ShortA.2.4.7.5 - Batch number
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. ReportOfImagingMethod.medication.dateTimeStart
Definition

Start Date: This is the time when the administration was started.

ShortA.2.4.7.6 - Start date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
98. ReportOfImagingMethod.medication.dateTimeEnd
Definition

End Date: The time the administration period ended (or was supposed to end).

ShortA.2.4.7.7 - End date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
100. ReportOfImagingMethod.medication.administrator
Definition

The healthcare professional who administered the medication.

ShortA.2.4.7.8 - Administrator
Control0..1
TypeHumanName
102. ReportOfImagingMethod.medication.reasonForSubmission
Definition

Reason for administering the medication. The patient's condition that was the reason for administering the medication or the observation that supports why the medication was administered.

ShortA.2.4.7.9 - Reason for submission
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
104. ReportOfImagingMethod.medication.comment
Definition

Comments on the administration of the medicinal product.

ShortA.2.4.7.10 - Comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
106. ReportOfImagingMethod.medication.dateTimeOfEntry
Definition

The date on which this information about the administration of the medicinal product is entered.

ShortA.2.4.7.11 - Entry date and time
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
108. ReportOfImagingMethod.adverseReaction
Definition

Adverse reactions related to medication or procedure.

ShortA.2.4.8 - Adverse reaction
Control0..*
TypeBase
110. ReportOfImagingMethod.adverseReaction.reaction
Definition

Reactions that are a manifestation of allergy or intolerance. These are events that may occur or have occurred in the past as a reaction to the cause of the allergy or intolerance.

  • Preferred system(s): SNOMED CT
ShortA.2.4.8.1 - Allergy code
Control1..*
TypeCodeableConcept
112. ReportOfImagingMethod.adverseReaction.seriousness
Definition

Severity of reaction due to medication or exposure.

  • Preferred system(s): SNOMED CT 'Mírná', 'Středně těžká', 'Těžká'
ShortA.2.4.8.2 - Allergy manifestation
Control0..1
TypeCodeableConcept
114. ReportOfImagingMethod.adverseReaction.dateTime
Definition

The date and time the reaction occurred. It can also be just a date or a partial date if the exact date is not known.

ShortA.2.4.8.3 - Alergy date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
116. ReportOfImagingMethod.adverseReaction.allergyDescription
Definition

Text description of the reaction as a whole.

ShortA.2.4.8.4 - Alergy description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
118. ReportOfImagingMethod.resultOfImagingMethod
Definition

Section Reports from imaging methods containing narrative result and optionally formalized result using coding systems

ShortA.2.4.9 - Result of the imaging method
Control1..1
TypeBase
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText
Definition

Summary textual (narrative) description of the results of imaging methods

ShortA.2.4.9.1 - Narrative text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText
Definition

Formalized structured result of the imaging method

ShortA.2.4.9.2 - Formalized text
Control0..*
TypeBase
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note
Definition

A note about the result. It should have an author and a timestamp.

ShortA.2.4.9.2.1 - Note
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
126. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationGroup
Definition

This is a grouping mechanism. An observation can be part of a group of observations (for example, a test panel) that are ordered, performed, or reported together.

ShortA.2.4.9.2.2 - Observation (measurement) group
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
128. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationComponent
Definition

Some observations have multiple sub-observations. These component observations are expressed as separate pairs of value codes that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurements and multiple component observations for genetic observations.

ShortA.2.4.9.2.3 - Observation (measurement) component
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
130. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.specimen
Definition

Information about the specimen used in the observation.

ShortA.2.4.9.2.4 - Specimen
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
132. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.referenceRanges
Definition

Information on the reference range relevant to the target population.

ShortA.2.4.9.2.5 - Reference ranges
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
134. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.reasonForAbsence
Definition

The reason why the expected value of the observation is missing.

ShortA.2.4.9.2.6 - The reason for the absence of a value
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
136. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationValue
Definition

The resulting value of the observation. There can be different types of values, either numeric, textual, coded, or raw data may be present.

ShortA.2.4.9.2.7 - Observation value (measurement)
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
138. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.interpretation
Definition

Interpretation of the result of observation (measurement).

ShortA.2.4.9.2.8 - Interpretation of the result
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
140. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationMethod
Definition

Information about the method, principle, or mechanism of observation.

ShortA.2.4.9.2.9 - Observation (measurement) method
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
142. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.derivedFrom
Definition

The source from which this observation value is derived. For example, fetal measurements based on an ultrasound image.

ShortA.2.4.9.2.10 - Derived from
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart
Definition

Specification of the observed body part.

ShortA.2.4.9.2.11 - Observed body part
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
146. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationStatus
Definition

The status of the observation as final, preliminary, or changed.

ShortA.2.4.9.2.12 - Observation status
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
148. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCode
Definition

Coded information about the type of observation.

  • Preferred system(s): SNOMED CT
ShortA.2.4.9.2.13 - Observation code
Control1..1
TypeCodeableConcept
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory
Definition

Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc.

ShortA.2.4.9.2.14 - Observation category
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
152. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationEquipment
Definition

The device used to make an observation and obtain a result.

ShortA.2.4.9.2.15 - Observation equipment used
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
154. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.dateTimeObservation
Definition

Date and time or period of observation.

ShortA.2.4.9.2.16 - Observation date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
156. ReportOfImagingMethod.resultOfImagingMethod.dateTimeResult
Definition

The date and time the observation was made available, usually after verification.

ShortA.2.4.9.3 - Result release date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
158. ReportOfImagingMethod.resultOfImagingMethod.author
Definition

The healthcare professional and/or healthcare provider organization where or by whom the observation was authorized.

ShortA.2.4.9.4 - Result author
Control0..1
TypeHumanName
160. ReportOfImagingMethod.conclusion
Definition

The conclusion summarizes the most important findings and/or diagnoses that were made based on the imaging findings (and possibly other clinical information). This section may include a coded assessment, such as BI-RADS categories or equivalent.

ShortA.2.4.10 - Conclusion
Control0..1
TypeBase
162. ReportOfImagingMethod.conclusion.text
Definition

Narrative text description of the clinical conclusion.

ShortA.2.4.10.1 - Conclusion text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
164. ReportOfImagingMethod.conclusion.code
Definition

Coded clinical findings - conditions or observations (one or the other). Commonly used staging systems (TNM, Bi-Rads, Li-Rads, etc.) can be expressed as a condition with staging (typically TNM, but also others) or as coded observations (Bi-Rads, Li-Rads, etc.).

  • Preferred system(s): TNM, Bi-Rads, Li-Rads
ShortA.2.4.10.2 - Coded conclusion
Control0..1
TypeCodeableConcept
166. ReportOfImagingMethod.recommendation
Definition

This section contains recommendations for follow-up examinations or procedures that resulted from the results and/or conclusions. The structured part of this item is identical to the item of the same name in the discharge report.

ShortA.2.4.11 - Recommendation
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
168. ReportOfImagingMethod.textPartsOfDocument
Definition

Summary text (narrative) parts of the document.

ShortA.2.4.12 - Text parts of the document
Control0..1
TypeBase
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport
Definition

The complete examination report, as issued.

ShortA.2.4.12.1 - Complete examination report
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
172. ReportOfImagingMethod.textPartsOfDocument.comments
Definition

Comments, such as textual interpretations or recommendations, that are part of the examination report.

ShortA.2.4.12.2 - Comments, interpretations and recommendations
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. ReportOfImagingMethod
Definition

Imaging Report - Imaging Report report of imaging method - A.2.4

ShortA.2.4 - Report of imaging method
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. ReportOfImagingMethod.typeOfModality
Definition

The type of modality that was used.

  • Preferred system(s): DICOM [ModalityCodelist]
ShortA.2.4.1 - Modality type
Control0..*
TypeCodeableConcept
4. ReportOfImagingMethod.typeOfImagingMethod
Definition

Display method type.

  • Preferred system(s): Valueset ČRK (ERTN)
  • Preferred system(s): LOINC Imaging Document Codes
ShortA.2.4.2 - Type of imaging method
Control1..*
TypeCodeableConcept
6. ReportOfImagingMethod.reason
Definition

Reason (indication)

ShortA.2.4.3 - Reason (indication)
Control0..*
TypeBase
8. ReportOfImagingMethod.reason.description
Definition

Description of the clinical condition, stating the reason why the imaging method was ordered (indicated). Example: "Cough lasting 3 months".

ShortA.2.4.3.1 - Description of the reason
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. ReportOfImagingMethod.reason.classification
Definition

Reason code for performing the display method.

  • Preferred system(s): SNOMED CT [ReasonCodelist]
ShortA.2.4.3.2 - Classification of reason
Control0..*
TypeCodeableConcept
12. ReportOfImagingMethod.clinicalQuestion
Definition

The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.'

ShortA.2.4.4 - A clinical question
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
14. ReportOfImagingMethod.partOfBody
Definition

The body part that is the subject of an examination or procedure. At least one of the Body Part Code or Description elements must be present.

ShortA.2.4.5 - Body part
Control0..*
TypeBase
16. ReportOfImagingMethod.partOfBody.code
Definition

Body part classification code, location on/in the body.

  • Preferred system(s): SNOMED CT [BodyLocation|LocationICT-O-3]
ShortA.2.4.5.1 - Body part code
Control0..1
TypeCodeableConcept
18. ReportOfImagingMethod.partOfBody.laterality
Definition

Sideness, if meaningful. (Location on the side of the body, if needed to distinguish from a similar location on the other side of the body. If laterality is present, body location must also be present.)

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.5.2 - Laterality of body part
Control0..1
TypeCodeableConcept
20. ReportOfImagingMethod.partOfBody.description
Definition

Human-readable description of the location on the body.

ShortA.2.4.5.3 - Body part description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. ReportOfImagingMethod.procedure
Definition

Description of the procedure expressed by code and/or text description. (E.g. used MR sequences, image projection...)

ShortA.2.4.6 - Performance (procedure)
Control0..*
TypeBase
24. ReportOfImagingMethod.procedure.reason
Definition

The reason for performing the procedure in a formalized or textual description.

ShortA.2.4.6.1 - Reason for performance
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
26. ReportOfImagingMethod.procedure.start
Definition

(Required) start date (and possibly start time) of the performance. It is permitted to provide a 'vague' date, e.g. only a year.

ShortA.2.4.6.2 - Start of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. ReportOfImagingMethod.procedure.end
Definition

The end date (and possibly the end time) of the service. It is allowed to specify an 'indefinite' date, e.g. only a year. The end date element is used only for services that last a certain time and then are always used. If the service is still ongoing, the value is left blank. For immediate or very short-term services, the element is omitted.

ShortA.2.4.6.3 - End of the procedure
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. ReportOfImagingMethod.procedure.performedBy
Definition

The healthcare professional and/or provider who performed the procedure.

ShortA.2.4.6.4 - Performed by
Control0..*
TypeHumanName
32. ReportOfImagingMethod.procedure.recordedBy
Definition

The healthcare professional who created the performance record and is responsible for its content.

ShortA.2.4.6.5 - Recorded by
Control0..1
TypeHumanName
34. ReportOfImagingMethod.procedure.place
Definition

Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination.

ShortA.2.4.6.6 - Place of performance
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
36. ReportOfImagingMethod.procedure.anatomicalFocus
Definition

The anatomical site where the procedure is targeted. Must contain at least one of the elements, either a code and/or a human-readable description of the site on/in the body.

ShortA.2.4.6.7 - Anatomical focus of performance
Control0..1
TypeBase
38. ReportOfImagingMethod.procedure.anatomicalFocus.code
Definition

The place on/in the body where the performance is focused.

  • Preferred system(s): SNOMED CT < 123037004 | Body structure
  • Preferred system(s): ICD-O-3 International Classification of Diseases for Oncology, version 3 (Topography codes)
ShortA.2.4.6.7.1 - Body location code
Control0..1
TypeCodeableConcept
40. ReportOfImagingMethod.procedure.anatomicalFocus.laterality
Definition

The location on the side of the body, if it is necessary to distinguish it from a similar location on the other side of the body. If laterality is present, the location of the location on/in the body must also be present.

  • Preferred system(s): SNOMED CT [Laterality Codelists]
ShortA.2.4.6.7.2 - Laterality of the body location
Control0..1
TypeCodeableConcept
42. ReportOfImagingMethod.procedure.anatomicalFocus.description
Definition

A human-readable description of the location on/in the body where the performance is targeted.

ShortA.2.4.6.7.3 - Description of the location on/in the body
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. ReportOfImagingMethod.procedure.complication
Definition

Any complications that occurred during or immediately after the procedure. These are usually tracked separately from the notes, which usually describe the procedure itself, not 'post-procedure' problems.

ShortA.2.4.6.8 - Complications during the procedure
Control0..*
TypeBase
46. ReportOfImagingMethod.procedure.complication.code
Definition

Indicating complications during or immediately after the procedure using a coding system.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.8.1 - Complications formalized
Control0..*
TypeCodeableConcept
48. ReportOfImagingMethod.procedure.complication.description
Definition

Textual (narrative) description of complications during or immediately after the procedure.

ShortA.2.4.6.8.2 - Description of complications
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. ReportOfImagingMethod.procedure.comment
Definition

Notes and comments on the performance (procedure).

ShortA.2.4.6.9 - Comment on the performance (procedure)
Control0..*
TypeBase
52. ReportOfImagingMethod.procedure.comment.author
Definition

Author of the comment.

ShortA.2.4.6.9.1 - Author of the comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. ReportOfImagingMethod.procedure.comment.text
Definition

Plain or formatted text content of the comment.

ShortA.2.4.6.9.2 - Text of the comment
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
56. ReportOfImagingMethod.procedure.comment.dateTime
Definition

When the comment was written. This element must be included if the information cannot be inferred from the context (e.g. from visit information, etc.).

ShortA.2.4.6.9.3 - Date and time of the comment
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
58. ReportOfImagingMethod.procedure.usedDevice
Definition

A medical device used during a procedure.

ShortA.2.4.6.10 - Used medical device
Control0..*
TypeBase
60. ReportOfImagingMethod.procedure.usedDevice.name
Definition

The brand name of the device or software.

ShortA.2.4.6.10.1 - Name of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
62. ReportOfImagingMethod.procedure.usedDevice.model
Definition

Device model or software version.

ShortA.2.4.6.10.2 - Medical device model
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
64. ReportOfImagingMethod.procedure.usedDevice.iden
Definition

Unique identifiers assigned to a device by the manufacturer, other organization, or owner, such as a serial number. A commonly used coding system is the GTIN.

ShortA.2.4.6.10.3 - Medical device ID
Control0..*
TypeIdentifier
66. ReportOfImagingMethod.procedure.usedDevice.type
Definition

Product type code.

  • Preferred system(s): SNOMED CT
  • Preferred system(s): EMDN
ShortA.2.4.6.10.4 - Type of medical device
Control0..1
TypeCodeableConcept
68. ReportOfImagingMethod.procedure.usedDevice.description
Definition

Additional text description/specification of the device.

ShortA.2.4.6.10.5 - Description of the medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
70. ReportOfImagingMethod.procedure.usedDevice.manufacturer
Definition

The name of the device or software manufacturer.

ShortA.2.4.6.10.6 - Manufacturer of medical device
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
72. ReportOfImagingMethod.procedure.usedDevice.udi
Definition

UDI of the medical device placed on the label or packaging of the device.

ShortA.2.4.6.10.7 - UDI of the medical device
Control0..1
TypeIdentifier
74. ReportOfImagingMethod.procedure.category
Definition

The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.

  • Preferred system(s): SNOMED CT [ProcedureCategoryCodelist]
ShortA.2.4.6.11 - Performance category (procedures)
Control0..*
TypeCodeableConcept
76. ReportOfImagingMethod.procedure.code
Definition

Code, or possibly name of the procedure.

  • Preferred system(s): SNOMED CT [ProcedureCodelist]
ShortA.2.4.6.12 - Performance (procedure)
Control1..1
TypeCodeableConcept
78. ReportOfImagingMethod.procedure.achievement
Definition

Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.

  • Preferred system(s): SNOMED CT
ShortA.2.4.6.13 - Achieving a result
Control0..1
TypeCodeableConcept
80. ReportOfImagingMethod.procedure.illnessCode
Definition

A detailed description or reference to information about the patient's health condition/health problem that is the reason for performing the procedure.

  • Preferred system(s): MKN-10
  • Preferred system(s): Orphacode
ShortA.2.4.6.14 - Illness - reason for the procedure
Control0..*
TypeCodeableConcept
82. ReportOfImagingMethod.procedure.relatedDevice
Definition

A medical device that is implanted, removed, or otherwise manipulated (calibration, battery replacement, prosthesis insertion, wound suction application, etc.) as a core part of a procedure.

ShortA.2.4.6.15 - Resource related
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
84. ReportOfImagingMethod.medication
Definition

Any substance administered in connection with a given procedure (typically a contrast agent, but it can also be another type of drug, e.g. a drug to reduce intestinal motility).

ShortA.2.4.7 - Medication
Control0..*
TypeBase
86. ReportOfImagingMethod.medication.name
Definition

The medication administered in connection with the examination (typically a contrast agent, but it can also be another type of medication, e.g. a medicine to reduce bowel motility). Usually these are medications. Food, blood products, devices and dressings do not strictly fall into the category of medications, but may also be recorded.

ShortA.2.4.7.1 - Administered medicinal product
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
88. ReportOfImagingMethod.medication.dosage
Definition

The dose of the medicinal product administered.

ShortA.2.4.7.2 - Dosage
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
90. ReportOfImagingMethod.medication.routeOfAdministration
Definition

The way in which the patient came into contact with the active substance or the way in which the active substance was administered.

  • Preferred system(s): SNOMED CT: <284009009 | Route of administration value
ShortA.2.4.7.3 - The route of administration of the active substance
Control0..1
TypeCodeableConcept
92. ReportOfImagingMethod.medication.dosingDevice
Definition

A device used to administer medication to a patient. For example, a specific infusion pump.

ShortA.2.4.7.4 - Dosing device
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
94. ReportOfImagingMethod.medication.batchNumber
Definition

Information related to the packaged products. The assigned batch number of the specified product. When this specific batch of the product will expire.

ShortA.2.4.7.5 - Batch number
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. ReportOfImagingMethod.medication.dateTimeStart
Definition

Start Date: This is the time when the administration was started.

ShortA.2.4.7.6 - Start date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
98. ReportOfImagingMethod.medication.dateTimeEnd
Definition

End Date: The time the administration period ended (or was supposed to end).

ShortA.2.4.7.7 - End date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
100. ReportOfImagingMethod.medication.administrator
Definition

The healthcare professional who administered the medication.

ShortA.2.4.7.8 - Administrator
Control0..1
TypeHumanName
102. ReportOfImagingMethod.medication.reasonForSubmission
Definition

Reason for administering the medication. The patient's condition that was the reason for administering the medication or the observation that supports why the medication was administered.

ShortA.2.4.7.9 - Reason for submission
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
104. ReportOfImagingMethod.medication.comment
Definition

Comments on the administration of the medicinal product.

ShortA.2.4.7.10 - Comment
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
106. ReportOfImagingMethod.medication.dateTimeOfEntry
Definition

The date on which this information about the administration of the medicinal product is entered.

ShortA.2.4.7.11 - Entry date and time
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
108. ReportOfImagingMethod.adverseReaction
Definition

Adverse reactions related to medication or procedure.

ShortA.2.4.8 - Adverse reaction
Control0..*
TypeBase
110. ReportOfImagingMethod.adverseReaction.reaction
Definition

Reactions that are a manifestation of allergy or intolerance. These are events that may occur or have occurred in the past as a reaction to the cause of the allergy or intolerance.

  • Preferred system(s): SNOMED CT
ShortA.2.4.8.1 - Allergy code
Control1..*
TypeCodeableConcept
112. ReportOfImagingMethod.adverseReaction.seriousness
Definition

Severity of reaction due to medication or exposure.

  • Preferred system(s): SNOMED CT 'Mírná', 'Středně těžká', 'Těžká'
ShortA.2.4.8.2 - Allergy manifestation
Control0..1
TypeCodeableConcept
114. ReportOfImagingMethod.adverseReaction.dateTime
Definition

The date and time the reaction occurred. It can also be just a date or a partial date if the exact date is not known.

ShortA.2.4.8.3 - Alergy date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
116. ReportOfImagingMethod.adverseReaction.allergyDescription
Definition

Text description of the reaction as a whole.

ShortA.2.4.8.4 - Alergy description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
118. ReportOfImagingMethod.resultOfImagingMethod
Definition

Section Reports from imaging methods containing narrative result and optionally formalized result using coding systems

ShortA.2.4.9 - Result of the imaging method
Control1..1
TypeBase
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText
Definition

Summary textual (narrative) description of the results of imaging methods

ShortA.2.4.9.1 - Narrative text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText
Definition

Formalized structured result of the imaging method

ShortA.2.4.9.2 - Formalized text
Control0..*
TypeBase
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note
Definition

A note about the result. It should have an author and a timestamp.

ShortA.2.4.9.2.1 - Note
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
126. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationGroup
Definition

This is a grouping mechanism. An observation can be part of a group of observations (for example, a test panel) that are ordered, performed, or reported together.

ShortA.2.4.9.2.2 - Observation (measurement) group
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
128. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationComponent
Definition

Some observations have multiple sub-observations. These component observations are expressed as separate pairs of value codes that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurements and multiple component observations for genetic observations.

ShortA.2.4.9.2.3 - Observation (measurement) component
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
130. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.specimen
Definition

Information about the specimen used in the observation.

ShortA.2.4.9.2.4 - Specimen
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
132. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.referenceRanges
Definition

Information on the reference range relevant to the target population.

ShortA.2.4.9.2.5 - Reference ranges
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
134. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.reasonForAbsence
Definition

The reason why the expected value of the observation is missing.

ShortA.2.4.9.2.6 - The reason for the absence of a value
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
136. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationValue
Definition

The resulting value of the observation. There can be different types of values, either numeric, textual, coded, or raw data may be present.

ShortA.2.4.9.2.7 - Observation value (measurement)
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
138. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.interpretation
Definition

Interpretation of the result of observation (measurement).

ShortA.2.4.9.2.8 - Interpretation of the result
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
140. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationMethod
Definition

Information about the method, principle, or mechanism of observation.

ShortA.2.4.9.2.9 - Observation (measurement) method
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
142. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.derivedFrom
Definition

The source from which this observation value is derived. For example, fetal measurements based on an ultrasound image.

ShortA.2.4.9.2.10 - Derived from
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart
Definition

Specification of the observed body part.

ShortA.2.4.9.2.11 - Observed body part
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
146. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationStatus
Definition

The status of the observation as final, preliminary, or changed.

ShortA.2.4.9.2.12 - Observation status
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
148. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCode
Definition

Coded information about the type of observation.

  • Preferred system(s): SNOMED CT
ShortA.2.4.9.2.13 - Observation code
Control1..1
TypeCodeableConcept
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory
Definition

Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc.

ShortA.2.4.9.2.14 - Observation category
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
152. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationEquipment
Definition

The device used to make an observation and obtain a result.

ShortA.2.4.9.2.15 - Observation equipment used
Control0..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
154. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.dateTimeObservation
Definition

Date and time or period of observation.

ShortA.2.4.9.2.16 - Observation date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
156. ReportOfImagingMethod.resultOfImagingMethod.dateTimeResult
Definition

The date and time the observation was made available, usually after verification.

ShortA.2.4.9.3 - Result release date and time
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
158. ReportOfImagingMethod.resultOfImagingMethod.author
Definition

The healthcare professional and/or healthcare provider organization where or by whom the observation was authorized.

ShortA.2.4.9.4 - Result author
Control0..1
TypeHumanName
160. ReportOfImagingMethod.conclusion
Definition

The conclusion summarizes the most important findings and/or diagnoses that were made based on the imaging findings (and possibly other clinical information). This section may include a coded assessment, such as BI-RADS categories or equivalent.

ShortA.2.4.10 - Conclusion
Control0..1
TypeBase
162. ReportOfImagingMethod.conclusion.text
Definition

Narrative text description of the clinical conclusion.

ShortA.2.4.10.1 - Conclusion text
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
164. ReportOfImagingMethod.conclusion.code
Definition

Coded clinical findings - conditions or observations (one or the other). Commonly used staging systems (TNM, Bi-Rads, Li-Rads, etc.) can be expressed as a condition with staging (typically TNM, but also others) or as coded observations (Bi-Rads, Li-Rads, etc.).

  • Preferred system(s): TNM, Bi-Rads, Li-Rads
ShortA.2.4.10.2 - Coded conclusion
Control0..1
TypeCodeableConcept
166. ReportOfImagingMethod.recommendation
Definition

This section contains recommendations for follow-up examinations or procedures that resulted from the results and/or conclusions. The structured part of this item is identical to the item of the same name in the discharge report.

ShortA.2.4.11 - Recommendation
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
168. ReportOfImagingMethod.textPartsOfDocument
Definition

Summary text (narrative) parts of the document.

ShortA.2.4.12 - Text parts of the document
Control0..1
TypeBase
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport
Definition

The complete examination report, as issued.

ShortA.2.4.12.1 - Complete examination report
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
172. ReportOfImagingMethod.textPartsOfDocument.comments
Definition

Comments, such as textual interpretations or recommendations, that are part of the examination report.

ShortA.2.4.12.2 - Comments, interpretations and recommendations
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension