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 - XML Representation

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="example-IDiagnosticReport-chest-xray"/>
  <meta>
    <profile
             value="https://profiles.ihe.net/RAD/IDR/StructureDefinition/imaging-diagnosticreport"/>
  </meta>
  <text>
    <status value="additional"/>
    <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>
  </text>
  <extension
             url="https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportComparison">
    <valueReference>🔗 
      <reference value="ImagingStudy/example-ImagingStudy-Comparison"/>
    </valueReference>
  </extension>
  <extension
             url="https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference">
    <valueReference>🔗 
      <reference value="Condition/example-Condition-Infarct"/>
    </valueReference>
  </extension>
  <extension
             url="https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportConclusionCodeReference">
    <valueReference>🔗 
      <reference value="Condition/example-Condition-Density"/>
    </valueReference>
  </extension>
  <extension
             url="https://profiles.ihe.net/RAD/IDR/StructureDefinition/idrDiagnosticReportRecommendation">
    <valueReference>🔗 
      <reference
                 value="ServiceRequest/example-ServiceRequest-Mammo-Recommendation"/>
    </valueReference>
  </extension>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="309964003"/>
      <display value="Radiology department"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://www.ama-assn.org/go/cpt"/>
      <code value="71045"/>
      <display value="RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/example-Patient"/>
  </subject>
  <issued value="2020-11-11T10:32:33-05:00"/>
  <performer>🔗 
    <reference value="Organization/example-Organization"/>
  </performer>
  <resultsInterpreter>🔗 
    <reference value="Practitioner/example-Practitioner-Radiologist"/>
  </resultsInterpreter>
  <study>🔗 
    <reference value="ImagingStudy/example-ImagingStudy"/>
  </study>
</DiagnosticReport>