Imaging Report - Imaging Report report of imaging method - A.2.4
The type of modality that was used. - Preferred system(s): DICOM [ModalityCodelist]
Display method type. - Preferred system(s): Valueset ČRK (ERTN) - Preferred system(s): LOINC Imaging Document Codes
Description of the clinical condition, stating the reason why the imaging method was ordered (indicated). Example: \"Cough lasting 3 months\".
Reason code for performing the display method. - Preferred system(s): SNOMED CT [ReasonCodelist]
The clinical question that the imaging method is intended to answer. Example: 'Suspected lung tumor.'
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.
Body part classification code, location on/in the body. - Preferred system(s): SNOMED CT [BodyLocation|LocationICT-O-3]
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]
Human-readable description of the location on the body.
Description of the procedure expressed by code and/or text description. (E.g. used MR sequences, image projection...)
The reason for performing the procedure in a formalized or textual description.
(Required) start date (and possibly start time) of the performance. It is permitted to provide a 'vague' date, e.g. only a year.
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.
The healthcare professional and/or provider who performed the procedure.
The healthcare professional who created the performance record and is responsible for its content.
Place (organization) where the procedure was performed. Only stated if different from the facility performing the imaging examination.
A.2.4.6.7 - Anatomical focus of performance
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.
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)
A.2.4.6.7.2 - Laterality of the body location
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]
A.2.4.6.7.3 - Description of the location on/in the body
A human-readable description of the location on/in the body where the performance is targeted.
A.2.4.6.8 - Complications during the procedure
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.
Indicating complications during or immediately after the procedure using a coding system. - Preferred system(s): SNOMED CT
A.2.4.6.8.2 - Description of complications
Textual (narrative) description of complications during or immediately after the procedure.
A.2.4.6.9 - Comment on the performance (procedure)
Notes and comments on the performance (procedure).
Plain or formatted text content of the comment.
A.2.4.6.9.3 - Date and time of the comment
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.).
A medical device used during a procedure.
The brand name of the device or software.
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.
Product type code. - Preferred system(s): SNOMED CT - Preferred system(s): EMDN
A.2.4.6.10.5 - Description of the medical device
Additional text description/specification of the device.
A.2.4.6.10.6 - Manufacturer of medical device
The name of the device or software manufacturer.
A.2.4.6.10.7 - UDI of the medical device
UDI of the medical device placed on the label or packaging of the device.
A.2.4.6.11 - Performance category (procedures)
The method or technique that was used to perform the procedure, e.g., access, irrigation, pressure, etc. - Preferred system(s): SNOMED CT [ProcedureCategoryCodelist]
Code, or possibly name of the procedure. - Preferred system(s): SNOMED CT [ProcedureCodelist]
Were the reasons why the procedure was performed resolved? 'Not resolved' … 'successful', 'unsuccessful', 'partially successful'. - Preferred system(s): SNOMED CT
A.2.4.6.14 - Illness - reason for the procedure
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
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.
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).
A.2.4.7.1 - Administered medicinal product
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.
The dose of the medicinal product administered.
A.2.4.7.3 - The route of administration of the active substance
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
A device used to administer medication to a patient. For example, a specific infusion pump.
Information related to the packaged products. The assigned batch number of the specified product. When this specific batch of the product will expire.
Start Date: This is the time when the administration was started.
End Date: The time the administration period ended (or was supposed to end).
The healthcare professional who administered the medication.
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.
Comments on the administration of the medicinal product.
The date on which this information about the administration of the medicinal product is entered.
Adverse reactions related to medication or procedure.
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
Severity of reaction due to medication or exposure. - Preferred system(s): SNOMED CT 'Mírná', 'Středně těžká', 'Těžká'
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.
Text description of the reaction as a whole.
Section Reports from imaging methods containing narrative result and optionally formalized result using coding systems
Summary textual (narrative) description of the results of imaging methods
Formalized structured result of the imaging method
A note about the result. It should have an author and a timestamp.
A.2.4.9.2.2 - Observation (measurement) group
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.
A.2.4.9.2.3 - Observation (measurement) component
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.
Information about the specimen used in the observation.
Information on the reference range relevant to the target population.
A.2.4.9.2.6 - The reason for the absence of a value
The reason why the expected value of the observation is missing.
A.2.4.9.2.7 - Observation value (measurement)
The resulting value of the observation. There can be different types of values, either numeric, textual, coded, or raw data may be present.
A.2.4.9.2.8 - Interpretation of the result
Interpretation of the result of observation (measurement).
A.2.4.9.2.9 - Observation (measurement) method
Information about the method, principle, or mechanism of observation.
The source from which this observation value is derived. For example, fetal measurements based on an ultrasound image.
Specification of the observed body part.
The status of the observation as final, preliminary, or changed.
Coded information about the type of observation. - Preferred system(s): SNOMED CT
Classification of the general category of observation, e.g. imaging, laboratory, vital signs, etc.
A.2.4.9.2.15 - Observation equipment used
The device used to make an observation and obtain a result.
A.2.4.9.2.16 - Observation date and time
A.2.4.9.3 - Result release date and time
The date and time the observation was made available, usually after verification.
The healthcare professional and/or healthcare provider organization where or by whom the observation was authorized.
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.
Narrative text description of the clinical conclusion.
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
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.
Summary text (narrative) parts of the document.
A.2.4.12.1 - Complete examination report
The complete examination report, as issued.
A.2.4.12.2 - Comments, interpretations and recommendations
Comments, such as textual interpretations or recommendations, that are part of the examination report.