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 - TTL Representation
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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:DiagnosticReport ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "example-IDiagnosticReport-chest-xray"] ; #
fhir:meta [
( fhir:profile [
fhir:v "https://profiles.ihe.net/RAD/IDR/StructureDefinition/imaging-diagnosticreport"^^xsd:anyURI ;
fhir:link <https://profiles.ihe.net/RAD/IDR/StructureDefinition/imaging-diagnosticreport> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "additional" ] ;
fhir: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>"^^rdf:XMLLiteral
] ; #
fhir:extension ( [
fhir:url [ fhir:v "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportComparison"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "ImagingStudy/example-ImagingStudy-Comparison" ] ]
] [
fhir:url [ fhir:v "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Condition/example-Condition-Infarct" ] ]
] [
fhir:url [ fhir:v "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Condition/example-Condition-Density" ] ]
] [
fhir:url [ fhir:v "https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportRecommendation"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "ServiceRequest/example-ServiceRequest-Mammo-Recommendation" ] ]
] ) ; #
fhir:status [ fhir:v "final"] ; #
fhir:category ( [
( fhir:coding [
a sct:309964003 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "309964003" ] ;
fhir:display [ fhir:v "Radiology department" ] ] )
] ) ; #
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "71045" ] ;
fhir:display [ fhir:v "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" ] ] )
] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/example-Patient" ]
] ; #
fhir:issued [ fhir:v "2020-11-11T10:32:33-05:00"^^xsd:dateTime] ; #
fhir:performer ( [
fhir:reference [ fhir:v "Organization/example-Organization" ]
] ) ; #
fhir:resultsInterpreter ( [
fhir:reference [ fhir:v "Practitioner/example-Practitioner-Radiologist" ]
] ) ; #
fhir:study ( [
fhir:reference [ fhir:v "ImagingStudy/example-ImagingStudy" ]
] ) . #
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