Imaging Diagnostic Report
0.0.1-current - ci-build International flag

Imaging Diagnostic Report, published by IHE Radiology Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/RAD.IDR/ and changes regularly. See the Directory of published versions

: A DiagnosticReport: XR Chest - JSON Representation

Raw json | Download

{
  "resourceType" : "DiagnosticReport",
  "id" : "example-IDiagnosticReport-chest-xray",
  "meta" : {
    "profile" : [
      🔗 "https://profiles.ihe.net/RAD/IDR/StructureDefinition/imaging-diagnosticreport"
    ]
  },
  "text" : {
    "status" : "additional",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Patient Name:</b> Jane Doe</p><p><b>Date of Examination:</b> 2020-11-11</p><div id=\"111\" class=\"loinc-55115-0\"><h2>Order:</h2><p><b>Referring Physician:</b> Welby, Marcus</p><p><b>Study:</b> Chest X-Ray (PA and Lateral views)</p><p><b>Indications:</b> Chest Pain, Shortness of Breath; Rule out pulmonary pathology</p></div><div id=\"222\" class=\"loinc-55111-9\"><h2>Procedure:</h2><p>Standard posteroanterior (PA) and lateral views of the chest were obtained. The study is of diagnostic quality, with satisfactory inspiration and penetration.</p></div><div id=\"333\" class=\"loinc-18834-2\"><h2>Comparison:</h2><ul><li>Chest X-Ray (Single view); 2020-01-05</li></ul></div><div id=\"444\" class=\"loinc-59776-5\"><h2>Findings:</h2><p>The cardiac silhouette is within normal size limits. Mediastinal contours are normal, with no evidence of widening or mediastinal shift.</p><p>The lung volumes are adequate and the vascular markings are within normal limits. A wedge-shaped opacity is noted in the right lower lobe, consistent with a pulmonary infarct. No obvious consolidation, significant pleural effusion, or other focal airspace disease is detected in the remaining lung fields.</p><p>The bony thorax, including the ribs, clavicles, and visible portions of the spine, shows no acute fracture or suspicious lytic/blastic lesions. Soft tissues of the chest wall are unremarkable, except for a small, suspicious density projected over the left breast region, which cannot be fully characterized on this examination.</p><p>The hemidiaphragms are smooth and sharply outlined. The costophrenic angles are clear. The visualized portions of the upper abdomen appear unremarkable.</p></div><div id=\"555\" class=\"loinc-19005-8\"><h2>Impression:</h2><ul><li>Right lower lobe pulmonary infarct consistent with the clinical scenario.</li><li>Suspicious soft tissue density overlying the left breast region that warrants further evaluation.</li></ul></div><div id=\"666\" class=\"loinc-18783-1\"><h2>Recommendation:</h2><ul><li>Bilateral diagnostic mammogram; to followup suspicious soft tissue density</li></ul></div></div>"
  },
  "extension" : [
    {
      "url" : "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportComparison",
      "valueReference" : {
        🔗 "reference" : "ImagingStudy/example-ImagingStudy-Comparison"
      }
    },
    {
      "url" : "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference",
      "valueReference" : {
        🔗 "reference" : "Condition/example-Condition-Infarct"
      }
    },
    {
      "url" : "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference",
      "valueReference" : {
        🔗 "reference" : "Condition/example-Condition-Density"
      }
    },
    {
      "url" : "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportRecommendation",
      "valueReference" : {
        🔗 "reference" : "ServiceRequest/example-ServiceRequest-Mammo-Recommendation"
      }
    }
  ],
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "309964003",
          "display" : "Radiology department"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://www.ama-assn.org/go/cpt",
        "code" : "71045",
        "display" : "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/example-Patient"
  },
  "issued" : "2020-11-11T10:32:33-05:00",
  "performer" : [
    {
      🔗 "reference" : "Organization/example-Organization"
    }
  ],
  "resultsInterpreter" : [
    {
      🔗 "reference" : "Practitioner/example-Practitioner-Radiologist"
    }
  ],
  "study" : [
    {
      🔗 "reference" : "ImagingStudy/example-ImagingStudy"
    }
  ]
}