HL7 Czech Imaging Report IG
0.1.0-ballot - ci-build
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
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 |
Short | A.2.4 - Report of imaging method |
Control | 0..* |
Is Modifier | false |
Logical Model | Instances 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.
|
Short | A.2.4.1 - Modality type |
Control | 0..* |
Type | CodeableConcept |
4. ReportOfImagingMethod.typeOfImagingMethod | |
Definition | Display method type.
|
Short | A.2.4.2 - Type of imaging method |
Control | 1..* |
Type | CodeableConcept |
6. ReportOfImagingMethod.reason | |
Definition | Reason (indication) |
Short | A.2.4.3 - Reason (indication) |
Control | 0..* |
Type | Base |
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". |
Short | A.2.4.3.1 - Description of the reason |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
10. ReportOfImagingMethod.reason.classification | |
Definition | Reason code for performing the display method.
|
Short | A.2.4.3.2 - Classification of reason |
Control | 0..* |
Type | CodeableConcept |
12. ReportOfImagingMethod.clinicalQuestion | |
Definition | The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.' |
Short | A.2.4.4 - A clinical question |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.5 - Body part |
Control | 0..* |
Type | Base |
16. ReportOfImagingMethod.partOfBody.code | |
Definition | Body part classification code, location on/in the body.
|
Short | A.2.4.5.1 - Body part code |
Control | 0..1 |
Type | CodeableConcept |
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.)
|
Short | A.2.4.5.2 - Laterality of body part |
Control | 0..1 |
Type | CodeableConcept |
20. ReportOfImagingMethod.partOfBody.description | |
Definition | Human-readable description of the location on the body. |
Short | A.2.4.5.3 - Body part description |
Control | 0..1 |
Type | string |
Primitive Value | This 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...) |
Short | A.2.4.6 - Performance (procedure) |
Control | 0..* |
Type | Base |
24. ReportOfImagingMethod.procedure.reason | |
Definition | The reason for performing the procedure in a formalized or textual description. |
Short | A.2.4.6.1 - Reason for performance |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.2 - Start of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.3 - End of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.4 - Performed by |
Control | 0..* |
Type | HumanName |
32. ReportOfImagingMethod.procedure.recordedBy | |
Definition | The healthcare professional who created the performance record and is responsible for its content. |
Short | A.2.4.6.5 - Recorded by |
Control | 0..1 |
Type | HumanName |
34. ReportOfImagingMethod.procedure.place | |
Definition | Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination. |
Short | A.2.4.6.6 - Place of performance |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.7 - Anatomical focus of performance |
Control | 0..1 |
Type | Base |
38. ReportOfImagingMethod.procedure.anatomicalFocus.code | |
Definition | The place on/in the body where the performance is focused.
|
Short | A.2.4.6.7.1 - Body location code |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.7.2 - Laterality of the body location |
Control | 0..1 |
Type | CodeableConcept |
42. ReportOfImagingMethod.procedure.anatomicalFocus.description | |
Definition | A human-readable description of the location on/in the body where the performance is targeted. |
Short | A.2.4.6.7.3 - Description of the location on/in the body |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.8 - Complications during the procedure |
Control | 0..* |
Type | Base |
46. ReportOfImagingMethod.procedure.complication.code | |
Definition | Indicating complications during or immediately after the procedure using a coding system.
|
Short | A.2.4.6.8.1 - Complications formalized |
Control | 0..* |
Type | CodeableConcept |
48. ReportOfImagingMethod.procedure.complication.description | |
Definition | Textual (narrative) description of complications during or immediately after the procedure. |
Short | A.2.4.6.8.2 - Description of complications |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
50. ReportOfImagingMethod.procedure.comment | |
Definition | Notes and comments on the performance (procedure). |
Short | A.2.4.6.9 - Comment on the performance (procedure) |
Control | 0..* |
Type | Base |
52. ReportOfImagingMethod.procedure.comment.author | |
Definition | Author of the comment. |
Short | A.2.4.6.9.1 - Author of the comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.9.2 - Text of the comment |
Control | 1..* |
Type | string |
Primitive Value | This 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.). |
Short | A.2.4.6.9.3 - Date and time of the comment |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
58. ReportOfImagingMethod.procedure.usedDevice | |
Definition | A medical device used during a procedure. |
Short | A.2.4.6.10 - Used medical device |
Control | 0..* |
Type | Base |
60. ReportOfImagingMethod.procedure.usedDevice.name | |
Definition | The brand name of the device or software. |
Short | A.2.4.6.10.1 - Name of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
62. ReportOfImagingMethod.procedure.usedDevice.model | |
Definition | Device model or software version. |
Short | A.2.4.6.10.2 - Medical device model |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.3 - Medical device ID |
Control | 0..* |
Type | Identifier |
66. ReportOfImagingMethod.procedure.usedDevice.type | |
Definition | Product type code.
|
Short | A.2.4.6.10.4 - Type of medical device |
Control | 0..1 |
Type | CodeableConcept |
68. ReportOfImagingMethod.procedure.usedDevice.description | |
Definition | Additional text description/specification of the device. |
Short | A.2.4.6.10.5 - Description of the medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.6 - Manufacturer of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.7 - UDI of the medical device |
Control | 0..1 |
Type | Identifier |
74. ReportOfImagingMethod.procedure.category | |
Definition | The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.
|
Short | A.2.4.6.11 - Performance category (procedures) |
Control | 0..* |
Type | CodeableConcept |
76. ReportOfImagingMethod.procedure.code | |
Definition | Code, or possibly name of the procedure.
|
Short | A.2.4.6.12 - Performance (procedure) |
Control | 1..1 |
Type | CodeableConcept |
78. ReportOfImagingMethod.procedure.achievement | |
Definition | Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.
|
Short | A.2.4.6.13 - Achieving a result |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.14 - Illness - reason for the procedure |
Control | 0..* |
Type | CodeableConcept |
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. |
Short | A.2.4.6.15 - Resource related |
Control | 0..* |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.7 - Medication |
Control | 0..* |
Type | Base |
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. |
Short | A.2.4.7.1 - Administered medicinal product |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
88. ReportOfImagingMethod.medication.dosage | |
Definition | The dose of the medicinal product administered. |
Short | A.2.4.7.2 - Dosage |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.7.3 - The route of administration of the active substance |
Control | 0..1 |
Type | CodeableConcept |
92. ReportOfImagingMethod.medication.dosingDevice | |
Definition | A device used to administer medication to a patient. For example, a specific infusion pump. |
Short | A.2.4.7.4 - Dosing device |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.5 - Batch number |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.6 - Start date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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). |
Short | A.2.4.7.7 - End date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
100. ReportOfImagingMethod.medication.administrator | |
Definition | The healthcare professional who administered the medication. |
Short | A.2.4.7.8 - Administrator |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.7.9 - Reason for submission |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.10 - Comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.11 - Entry date and time |
Control | 1..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
108. ReportOfImagingMethod.adverseReaction | |
Definition | Adverse reactions related to medication or procedure. |
Short | A.2.4.8 - Adverse reaction |
Control | 0..* |
Type | Base |
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.
|
Short | A.2.4.8.1 - Allergy code |
Control | 1..* |
Type | CodeableConcept |
112. ReportOfImagingMethod.adverseReaction.seriousness | |
Definition | Severity of reaction due to medication or exposure.
|
Short | A.2.4.8.2 - Allergy manifestation |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.8.3 - Alergy date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.8.4 - Alergy description |
Control | 0..1 |
Type | string |
Primitive Value | This 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 |
Short | A.2.4.9 - Result of the imaging method |
Control | 1..1 |
Type | Base |
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText | |
Definition | Summary textual (narrative) description of the results of imaging methods |
Short | A.2.4.9.1 - Narrative text |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText | |
Definition | Formalized structured result of the imaging method |
Short | A.2.4.9.2 - Formalized text |
Control | 0..* |
Type | Base |
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note | |
Definition | A note about the result. It should have an author and a timestamp. |
Short | A.2.4.9.2.1 - Note |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.2 - Observation (measurement) group |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.3 - Observation (measurement) component |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.4 - Specimen |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.5 - Reference ranges |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.6 - The reason for the absence of a value |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.7 - Observation value (measurement) |
Control | 0..1 |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.9.2.8 - Interpretation of the result |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.9 - Observation (measurement) method |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.10 - Derived from |
Control | 0..* |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart | |
Definition | Specification of the observed body part. |
Short | A.2.4.9.2.11 - Observed body part |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.12 - Observation status |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.9.2.13 - Observation code |
Control | 1..1 |
Type | CodeableConcept |
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory | |
Definition | Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc. |
Short | A.2.4.9.2.14 - Observation category |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.15 - Observation equipment used |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.16 - Observation date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.3 - Result release date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.4 - Result author |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.10 - Conclusion |
Control | 0..1 |
Type | Base |
162. ReportOfImagingMethod.conclusion.text | |
Definition | Narrative text description of the clinical conclusion. |
Short | A.2.4.10.1 - Conclusion text |
Control | 1..1 |
Type | string |
Primitive Value | This 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.).
|
Short | A.2.4.10.2 - Coded conclusion |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.11 - Recommendation |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
168. ReportOfImagingMethod.textPartsOfDocument | |
Definition | Summary text (narrative) parts of the document. |
Short | A.2.4.12 - Text parts of the document |
Control | 0..1 |
Type | Base |
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport | |
Definition | The complete examination report, as issued. |
Short | A.2.4.12.1 - Complete examination report |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.12.2 - Comments, interpretations and recommendations |
Control | 0..1 |
Type | string |
Primitive Value | This 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 |
Short | A.2.4 - Report of imaging method |
Logical Model | Instances 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.
|
Short | A.2.4.1 - Modality type |
Control | 0..* |
Type | CodeableConcept |
4. ReportOfImagingMethod.typeOfImagingMethod | |
Definition | Display method type.
|
Short | A.2.4.2 - Type of imaging method |
Control | 1..* |
Type | CodeableConcept |
6. ReportOfImagingMethod.reason | |
Definition | Reason (indication) |
Short | A.2.4.3 - Reason (indication) |
Control | 0..* |
Type | Base |
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". |
Short | A.2.4.3.1 - Description of the reason |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
10. ReportOfImagingMethod.reason.classification | |
Definition | Reason code for performing the display method.
|
Short | A.2.4.3.2 - Classification of reason |
Control | 0..* |
Type | CodeableConcept |
12. ReportOfImagingMethod.clinicalQuestion | |
Definition | The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.' |
Short | A.2.4.4 - A clinical question |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.5 - Body part |
Control | 0..* |
Type | Base |
16. ReportOfImagingMethod.partOfBody.code | |
Definition | Body part classification code, location on/in the body.
|
Short | A.2.4.5.1 - Body part code |
Control | 0..1 |
Type | CodeableConcept |
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.)
|
Short | A.2.4.5.2 - Laterality of body part |
Control | 0..1 |
Type | CodeableConcept |
20. ReportOfImagingMethod.partOfBody.description | |
Definition | Human-readable description of the location on the body. |
Short | A.2.4.5.3 - Body part description |
Control | 0..1 |
Type | string |
Primitive Value | This 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...) |
Short | A.2.4.6 - Performance (procedure) |
Control | 0..* |
Type | Base |
24. ReportOfImagingMethod.procedure.reason | |
Definition | The reason for performing the procedure in a formalized or textual description. |
Short | A.2.4.6.1 - Reason for performance |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.2 - Start of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.3 - End of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.4 - Performed by |
Control | 0..* |
Type | HumanName |
32. ReportOfImagingMethod.procedure.recordedBy | |
Definition | The healthcare professional who created the performance record and is responsible for its content. |
Short | A.2.4.6.5 - Recorded by |
Control | 0..1 |
Type | HumanName |
34. ReportOfImagingMethod.procedure.place | |
Definition | Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination. |
Short | A.2.4.6.6 - Place of performance |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.7 - Anatomical focus of performance |
Control | 0..1 |
Type | Base |
38. ReportOfImagingMethod.procedure.anatomicalFocus.code | |
Definition | The place on/in the body where the performance is focused.
|
Short | A.2.4.6.7.1 - Body location code |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.7.2 - Laterality of the body location |
Control | 0..1 |
Type | CodeableConcept |
42. ReportOfImagingMethod.procedure.anatomicalFocus.description | |
Definition | A human-readable description of the location on/in the body where the performance is targeted. |
Short | A.2.4.6.7.3 - Description of the location on/in the body |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.8 - Complications during the procedure |
Control | 0..* |
Type | Base |
46. ReportOfImagingMethod.procedure.complication.code | |
Definition | Indicating complications during or immediately after the procedure using a coding system.
|
Short | A.2.4.6.8.1 - Complications formalized |
Control | 0..* |
Type | CodeableConcept |
48. ReportOfImagingMethod.procedure.complication.description | |
Definition | Textual (narrative) description of complications during or immediately after the procedure. |
Short | A.2.4.6.8.2 - Description of complications |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
50. ReportOfImagingMethod.procedure.comment | |
Definition | Notes and comments on the performance (procedure). |
Short | A.2.4.6.9 - Comment on the performance (procedure) |
Control | 0..* |
Type | Base |
52. ReportOfImagingMethod.procedure.comment.author | |
Definition | Author of the comment. |
Short | A.2.4.6.9.1 - Author of the comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.9.2 - Text of the comment |
Control | 1..* |
Type | string |
Primitive Value | This 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.). |
Short | A.2.4.6.9.3 - Date and time of the comment |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
58. ReportOfImagingMethod.procedure.usedDevice | |
Definition | A medical device used during a procedure. |
Short | A.2.4.6.10 - Used medical device |
Control | 0..* |
Type | Base |
60. ReportOfImagingMethod.procedure.usedDevice.name | |
Definition | The brand name of the device or software. |
Short | A.2.4.6.10.1 - Name of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
62. ReportOfImagingMethod.procedure.usedDevice.model | |
Definition | Device model or software version. |
Short | A.2.4.6.10.2 - Medical device model |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.3 - Medical device ID |
Control | 0..* |
Type | Identifier |
66. ReportOfImagingMethod.procedure.usedDevice.type | |
Definition | Product type code.
|
Short | A.2.4.6.10.4 - Type of medical device |
Control | 0..1 |
Type | CodeableConcept |
68. ReportOfImagingMethod.procedure.usedDevice.description | |
Definition | Additional text description/specification of the device. |
Short | A.2.4.6.10.5 - Description of the medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.6 - Manufacturer of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.7 - UDI of the medical device |
Control | 0..1 |
Type | Identifier |
74. ReportOfImagingMethod.procedure.category | |
Definition | The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.
|
Short | A.2.4.6.11 - Performance category (procedures) |
Control | 0..* |
Type | CodeableConcept |
76. ReportOfImagingMethod.procedure.code | |
Definition | Code, or possibly name of the procedure.
|
Short | A.2.4.6.12 - Performance (procedure) |
Control | 1..1 |
Type | CodeableConcept |
78. ReportOfImagingMethod.procedure.achievement | |
Definition | Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.
|
Short | A.2.4.6.13 - Achieving a result |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.14 - Illness - reason for the procedure |
Control | 0..* |
Type | CodeableConcept |
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. |
Short | A.2.4.6.15 - Resource related |
Control | 0..* |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.7 - Medication |
Control | 0..* |
Type | Base |
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. |
Short | A.2.4.7.1 - Administered medicinal product |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
88. ReportOfImagingMethod.medication.dosage | |
Definition | The dose of the medicinal product administered. |
Short | A.2.4.7.2 - Dosage |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.7.3 - The route of administration of the active substance |
Control | 0..1 |
Type | CodeableConcept |
92. ReportOfImagingMethod.medication.dosingDevice | |
Definition | A device used to administer medication to a patient. For example, a specific infusion pump. |
Short | A.2.4.7.4 - Dosing device |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.5 - Batch number |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.6 - Start date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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). |
Short | A.2.4.7.7 - End date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
100. ReportOfImagingMethod.medication.administrator | |
Definition | The healthcare professional who administered the medication. |
Short | A.2.4.7.8 - Administrator |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.7.9 - Reason for submission |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.10 - Comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.11 - Entry date and time |
Control | 1..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
108. ReportOfImagingMethod.adverseReaction | |
Definition | Adverse reactions related to medication or procedure. |
Short | A.2.4.8 - Adverse reaction |
Control | 0..* |
Type | Base |
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.
|
Short | A.2.4.8.1 - Allergy code |
Control | 1..* |
Type | CodeableConcept |
112. ReportOfImagingMethod.adverseReaction.seriousness | |
Definition | Severity of reaction due to medication or exposure.
|
Short | A.2.4.8.2 - Allergy manifestation |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.8.3 - Alergy date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.8.4 - Alergy description |
Control | 0..1 |
Type | string |
Primitive Value | This 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 |
Short | A.2.4.9 - Result of the imaging method |
Control | 1..1 |
Type | Base |
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText | |
Definition | Summary textual (narrative) description of the results of imaging methods |
Short | A.2.4.9.1 - Narrative text |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText | |
Definition | Formalized structured result of the imaging method |
Short | A.2.4.9.2 - Formalized text |
Control | 0..* |
Type | Base |
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note | |
Definition | A note about the result. It should have an author and a timestamp. |
Short | A.2.4.9.2.1 - Note |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.2 - Observation (measurement) group |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.3 - Observation (measurement) component |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.4 - Specimen |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.5 - Reference ranges |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.6 - The reason for the absence of a value |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.7 - Observation value (measurement) |
Control | 0..1 |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.9.2.8 - Interpretation of the result |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.9 - Observation (measurement) method |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.10 - Derived from |
Control | 0..* |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart | |
Definition | Specification of the observed body part. |
Short | A.2.4.9.2.11 - Observed body part |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.12 - Observation status |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.9.2.13 - Observation code |
Control | 1..1 |
Type | CodeableConcept |
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory | |
Definition | Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc. |
Short | A.2.4.9.2.14 - Observation category |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.15 - Observation equipment used |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.16 - Observation date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.3 - Result release date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.4 - Result author |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.10 - Conclusion |
Control | 0..1 |
Type | Base |
162. ReportOfImagingMethod.conclusion.text | |
Definition | Narrative text description of the clinical conclusion. |
Short | A.2.4.10.1 - Conclusion text |
Control | 1..1 |
Type | string |
Primitive Value | This 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.).
|
Short | A.2.4.10.2 - Coded conclusion |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.11 - Recommendation |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
168. ReportOfImagingMethod.textPartsOfDocument | |
Definition | Summary text (narrative) parts of the document. |
Short | A.2.4.12 - Text parts of the document |
Control | 0..1 |
Type | Base |
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport | |
Definition | The complete examination report, as issued. |
Short | A.2.4.12.1 - Complete examination report |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.12.2 - Comments, interpretations and recommendations |
Control | 0..1 |
Type | string |
Primitive Value | This 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 |
Short | A.2.4 - Report of imaging method |
Control | 0..* |
Is Modifier | false |
Logical Model | Instances 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.
|
Short | A.2.4.1 - Modality type |
Control | 0..* |
Type | CodeableConcept |
4. ReportOfImagingMethod.typeOfImagingMethod | |
Definition | Display method type.
|
Short | A.2.4.2 - Type of imaging method |
Control | 1..* |
Type | CodeableConcept |
6. ReportOfImagingMethod.reason | |
Definition | Reason (indication) |
Short | A.2.4.3 - Reason (indication) |
Control | 0..* |
Type | Base |
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". |
Short | A.2.4.3.1 - Description of the reason |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
10. ReportOfImagingMethod.reason.classification | |
Definition | Reason code for performing the display method.
|
Short | A.2.4.3.2 - Classification of reason |
Control | 0..* |
Type | CodeableConcept |
12. ReportOfImagingMethod.clinicalQuestion | |
Definition | The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.' |
Short | A.2.4.4 - A clinical question |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.5 - Body part |
Control | 0..* |
Type | Base |
16. ReportOfImagingMethod.partOfBody.code | |
Definition | Body part classification code, location on/in the body.
|
Short | A.2.4.5.1 - Body part code |
Control | 0..1 |
Type | CodeableConcept |
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.)
|
Short | A.2.4.5.2 - Laterality of body part |
Control | 0..1 |
Type | CodeableConcept |
20. ReportOfImagingMethod.partOfBody.description | |
Definition | Human-readable description of the location on the body. |
Short | A.2.4.5.3 - Body part description |
Control | 0..1 |
Type | string |
Primitive Value | This 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...) |
Short | A.2.4.6 - Performance (procedure) |
Control | 0..* |
Type | Base |
24. ReportOfImagingMethod.procedure.reason | |
Definition | The reason for performing the procedure in a formalized or textual description. |
Short | A.2.4.6.1 - Reason for performance |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.2 - Start of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.3 - End of the procedure |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.6.4 - Performed by |
Control | 0..* |
Type | HumanName |
32. ReportOfImagingMethod.procedure.recordedBy | |
Definition | The healthcare professional who created the performance record and is responsible for its content. |
Short | A.2.4.6.5 - Recorded by |
Control | 0..1 |
Type | HumanName |
34. ReportOfImagingMethod.procedure.place | |
Definition | Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination. |
Short | A.2.4.6.6 - Place of performance |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.7 - Anatomical focus of performance |
Control | 0..1 |
Type | Base |
38. ReportOfImagingMethod.procedure.anatomicalFocus.code | |
Definition | The place on/in the body where the performance is focused.
|
Short | A.2.4.6.7.1 - Body location code |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.7.2 - Laterality of the body location |
Control | 0..1 |
Type | CodeableConcept |
42. ReportOfImagingMethod.procedure.anatomicalFocus.description | |
Definition | A human-readable description of the location on/in the body where the performance is targeted. |
Short | A.2.4.6.7.3 - Description of the location on/in the body |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.8 - Complications during the procedure |
Control | 0..* |
Type | Base |
46. ReportOfImagingMethod.procedure.complication.code | |
Definition | Indicating complications during or immediately after the procedure using a coding system.
|
Short | A.2.4.6.8.1 - Complications formalized |
Control | 0..* |
Type | CodeableConcept |
48. ReportOfImagingMethod.procedure.complication.description | |
Definition | Textual (narrative) description of complications during or immediately after the procedure. |
Short | A.2.4.6.8.2 - Description of complications |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
50. ReportOfImagingMethod.procedure.comment | |
Definition | Notes and comments on the performance (procedure). |
Short | A.2.4.6.9 - Comment on the performance (procedure) |
Control | 0..* |
Type | Base |
52. ReportOfImagingMethod.procedure.comment.author | |
Definition | Author of the comment. |
Short | A.2.4.6.9.1 - Author of the comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.9.2 - Text of the comment |
Control | 1..* |
Type | string |
Primitive Value | This 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.). |
Short | A.2.4.6.9.3 - Date and time of the comment |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
58. ReportOfImagingMethod.procedure.usedDevice | |
Definition | A medical device used during a procedure. |
Short | A.2.4.6.10 - Used medical device |
Control | 0..* |
Type | Base |
60. ReportOfImagingMethod.procedure.usedDevice.name | |
Definition | The brand name of the device or software. |
Short | A.2.4.6.10.1 - Name of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
62. ReportOfImagingMethod.procedure.usedDevice.model | |
Definition | Device model or software version. |
Short | A.2.4.6.10.2 - Medical device model |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.3 - Medical device ID |
Control | 0..* |
Type | Identifier |
66. ReportOfImagingMethod.procedure.usedDevice.type | |
Definition | Product type code.
|
Short | A.2.4.6.10.4 - Type of medical device |
Control | 0..1 |
Type | CodeableConcept |
68. ReportOfImagingMethod.procedure.usedDevice.description | |
Definition | Additional text description/specification of the device. |
Short | A.2.4.6.10.5 - Description of the medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.6 - Manufacturer of medical device |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.6.10.7 - UDI of the medical device |
Control | 0..1 |
Type | Identifier |
74. ReportOfImagingMethod.procedure.category | |
Definition | The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc.
|
Short | A.2.4.6.11 - Performance category (procedures) |
Control | 0..* |
Type | CodeableConcept |
76. ReportOfImagingMethod.procedure.code | |
Definition | Code, or possibly name of the procedure.
|
Short | A.2.4.6.12 - Performance (procedure) |
Control | 1..1 |
Type | CodeableConcept |
78. ReportOfImagingMethod.procedure.achievement | |
Definition | Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'.
|
Short | A.2.4.6.13 - Achieving a result |
Control | 0..1 |
Type | CodeableConcept |
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.
|
Short | A.2.4.6.14 - Illness - reason for the procedure |
Control | 0..* |
Type | CodeableConcept |
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. |
Short | A.2.4.6.15 - Resource related |
Control | 0..* |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.7 - Medication |
Control | 0..* |
Type | Base |
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. |
Short | A.2.4.7.1 - Administered medicinal product |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
88. ReportOfImagingMethod.medication.dosage | |
Definition | The dose of the medicinal product administered. |
Short | A.2.4.7.2 - Dosage |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.7.3 - The route of administration of the active substance |
Control | 0..1 |
Type | CodeableConcept |
92. ReportOfImagingMethod.medication.dosingDevice | |
Definition | A device used to administer medication to a patient. For example, a specific infusion pump. |
Short | A.2.4.7.4 - Dosing device |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.5 - Batch number |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.6 - Start date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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). |
Short | A.2.4.7.7 - End date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
100. ReportOfImagingMethod.medication.administrator | |
Definition | The healthcare professional who administered the medication. |
Short | A.2.4.7.8 - Administrator |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.7.9 - Reason for submission |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.10 - Comment |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.7.11 - Entry date and time |
Control | 1..1 |
Type | dateTime |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
108. ReportOfImagingMethod.adverseReaction | |
Definition | Adverse reactions related to medication or procedure. |
Short | A.2.4.8 - Adverse reaction |
Control | 0..* |
Type | Base |
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.
|
Short | A.2.4.8.1 - Allergy code |
Control | 1..* |
Type | CodeableConcept |
112. ReportOfImagingMethod.adverseReaction.seriousness | |
Definition | Severity of reaction due to medication or exposure.
|
Short | A.2.4.8.2 - Allergy manifestation |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.8.3 - Alergy date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.8.4 - Alergy description |
Control | 0..1 |
Type | string |
Primitive Value | This 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 |
Short | A.2.4.9 - Result of the imaging method |
Control | 1..1 |
Type | Base |
120. ReportOfImagingMethod.resultOfImagingMethod.narrativeText | |
Definition | Summary textual (narrative) description of the results of imaging methods |
Short | A.2.4.9.1 - Narrative text |
Control | 1..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
122. ReportOfImagingMethod.resultOfImagingMethod.formalizedText | |
Definition | Formalized structured result of the imaging method |
Short | A.2.4.9.2 - Formalized text |
Control | 0..* |
Type | Base |
124. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.note | |
Definition | A note about the result. It should have an author and a timestamp. |
Short | A.2.4.9.2.1 - Note |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.2 - Observation (measurement) group |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.3 - Observation (measurement) component |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.4 - Specimen |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.5 - Reference ranges |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.6 - The reason for the absence of a value |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.7 - Observation value (measurement) |
Control | 0..1 |
Type | string |
Primitive Value | This 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). |
Short | A.2.4.9.2.8 - Interpretation of the result |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.9 - Observation (measurement) method |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.10 - Derived from |
Control | 0..* |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
144. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observedBodyPart | |
Definition | Specification of the observed body part. |
Short | A.2.4.9.2.11 - Observed body part |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.12 - Observation status |
Control | 0..1 |
Type | string |
Primitive Value | This 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.
|
Short | A.2.4.9.2.13 - Observation code |
Control | 1..1 |
Type | CodeableConcept |
150. ReportOfImagingMethod.resultOfImagingMethod.formalizedText.observationCategory | |
Definition | Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc. |
Short | A.2.4.9.2.14 - Observation category |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.15 - Observation equipment used |
Control | 0..* |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.9.2.16 - Observation date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.3 - Result release date and time |
Control | 0..1 |
Type | dateTime |
Primitive Value | This 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. |
Short | A.2.4.9.4 - Result author |
Control | 0..1 |
Type | HumanName |
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. |
Short | A.2.4.10 - Conclusion |
Control | 0..1 |
Type | Base |
162. ReportOfImagingMethod.conclusion.text | |
Definition | Narrative text description of the clinical conclusion. |
Short | A.2.4.10.1 - Conclusion text |
Control | 1..1 |
Type | string |
Primitive Value | This 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.).
|
Short | A.2.4.10.2 - Coded conclusion |
Control | 0..1 |
Type | CodeableConcept |
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. |
Short | A.2.4.11 - Recommendation |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
168. ReportOfImagingMethod.textPartsOfDocument | |
Definition | Summary text (narrative) parts of the document. |
Short | A.2.4.12 - Text parts of the document |
Control | 0..1 |
Type | Base |
170. ReportOfImagingMethod.textPartsOfDocument.completeExaminationReport | |
Definition | The complete examination report, as issued. |
Short | A.2.4.12.1 - Complete examination report |
Control | 0..1 |
Type | string |
Primitive Value | This 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. |
Short | A.2.4.12.2 - Comments, interpretations and recommendations |
Control | 0..1 |
Type | string |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |