Breast Imaging Reporting - 2nd STU ballot, published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.3.0). This version is based on the current content of https://github.com/HL7/fhir-breast-radiology-ig/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/breast-radiology/StructureDefinition/BreastImagingReport | Version: 0.3.0 | |||
Draft as of 2019-11-01 | Computable Name: BreastImagingReport |
Breast Imaging Diagnostic Report.
Description
This resource is one of the components of a Breast Imaging Composition.
Each Breast Imaging Composition will contain exactly one Breast Imaging Report instance that is referenced in the composition's 'Report' section.
This instance will contain the top level results of the exam, including the narrative result.
The report may be a 'traditional' mammography report, or it may be a newer type of report such as a "3D mammography exam report". The Breast Imaging Document contains sections for commonly used modalities such as mammography, ultrasource and nuclear medicine, and also has a place for 'other' modalities.
Graphical Overview
This graph provides an overview of this profile, and its dependencies.
Click on any of the elements of the graph to go to a section describing that element.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for category | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this | |
category:categoryImaging | 1..1 | CodeableConcept | Service category Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) | |
specimen | 0..0 | |||
result | 0..0 | |||
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this | |
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |
Documentation for this format |
Path | Conformance | ValueSet |
DiagnosticReport.code | required | BreastImagingReportTypesVS |
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) |
category:categoryImaging | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 1..1 | Reference(Media) | Reference to the image source |
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet / Code |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory |
DiagnosticReport.category:categoryImaging | example | Pattern: imaging |
DiagnosticReport.code | required | BreastImagingReportTypesVS |
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
category:categoryImaging | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered | ||||
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | DateTime this version was made | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | SΣ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory | ||||
DiagnosticReport.category:categoryImaging | example | Pattern: imaging | ||||
DiagnosticReport.code | required | BreastImagingReportTypesVS | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings | ||||
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 1 element
Prohibited: 2 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for category | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this | |
category:categoryImaging | 1..1 | CodeableConcept | Service category Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) | |
specimen | 0..0 | |||
result | 0..0 | |||
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this | |
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |
Documentation for this format |
Path | Conformance | ValueSet |
DiagnosticReport.code | required | BreastImagingReportTypesVS |
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) |
category:categoryImaging | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | Responsible Diagnostic Service |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 1..1 | Reference(Media) | Reference to the image source |
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet / Code |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory |
DiagnosticReport.category:categoryImaging | example | Pattern: imaging |
DiagnosticReport.code | required | BreastImagingReportTypesVS |
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
category:categoryImaging | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: Breast Imaging Report Types ValueSet (required) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Health care event when test ordered | ||||
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | DateTime this version was made | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | SΣ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
Slices for conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Slice: Unordered, Open by pattern:$this Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
conclusionCode:BiRads | 0..1 | CodeableConcept | BiRads assessment value. Binding: Breast Assessment Category ValueSet (required) | |||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory | ||||
DiagnosticReport.category:categoryImaging | example | Pattern: imaging | ||||
DiagnosticReport.code | required | BreastImagingReportTypesVS | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings | ||||
DiagnosticReport.conclusionCode:BiRads | required | BreastAssessmentCategoryVS |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 1 element
Prohibited: 2 elements
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron