Imaging Diagnostic Report
0.0.1-current - ci-build
Imaging Diagnostic Report
0.0.1-current - ci-build
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
This IHE Radiology Content Specification defines standard encodings for diagnostic reports on imaging procedures. It is specifically intended to cover the output of reporting systems following the interpretation performed by an imaging clinician such as a radiologist.
Refer to IHE RAD TF-1:56.4.1.2 for real world expectations in the various report sections.
Pathology and Interventional procedures are not specifically addressed.
FHIR-R4: HL7 FHIR Release 4.0
FHIR-R5: HL7 FHIR Release 5.0
FHIR R6
FHIR ImagingSelection: ImagingSelection
LATER – Reference other FHIR Resources
Implementations shall support the use of FHIR R4 resources.
Implementations may also be configurable to support the use of FHIR R5 and/or FHIR R6 resources.
This profile depends on a number of extensions introduced in FHIR R5 and FHIR R6 to address key details for coded imaging diagnostic reports.
When encoding or parsing FHIR R4 resources, implementations shall support the additional elements specified in this Profile as extensions in the manner described here: https://build.fhir.org/versions.html#extensions
Implementers may find one or more “FHIR extension packs” available to facilitate the support of elements introduced in FHIR R5 (and/or eventually FHIR R6).
TODO Update the text to more specifically describe the IDR-R4-to-R5-and-R6 extensions mechanism, and any IDR extensions (which go beyond R4/5/6)
This content definition makes normative profiling changes to the following FHIR Resources:
ServiceRequest (Recommendation)
Procedure (Imaging Procedure)
ImagingStudy (Reported or Comparison Study) - DICOM Study UID & text
Observation (History)
Condition (Impression)
This content definition makes only usage clarifications to the following FHIR Resources:
This content definition uses without change the following FHIR Resources:
Encounter (Imaging Encounter)
Provenance
The Report Creator is expected to populate much of the contextual metadata (e.g., patient demographics, patient identifiers and issuers, study accession number, etc.) in the imaging diagnostic report resources based on values in the medical imaging data being processed, and/or the reporting worklist entry.
This content definition does not presume that all semantics in the report that are potentially codeable are actually coded in this resource. Profiles will likely identify some specific details which are required to be coded to conform to that profile; however, systems processing diagnostic reports should generally assume that there may be details in the narrative which are not also encoded. See also TOLINK RAD TF-1: 56.4.1.6 Narrative vs Encoded Content and Structure.
Note: This profile changes the cardinality from 0.. to 1.. for some FHIR resource attributes. This is done when absence of the attribute would break interoperability. It is not done to enforce the presence of information that is simply desirable or convenient.
This section describes requirements that are also represented in a companion IDR FHIR IG (Implementation Guide). Some of these requirements involve extensions to the FHIR Resources.
TODO: Since there is the risk that reiterated/duplicated content could diverge, any remaining content here will likely be reframed as informative and moved to Concepts, to an Informative Annex, to an IG Resource page, or dropped if all the discussion can be conveniently captured in the IG.
In IMR, there is no Vol 3 Content Definition; the IMR Transactions reference directly to Profiled Resource pages in the IG. Finding a way to splice FHIR IGs into Content Definitions might be another option. Discuss with Lynn/ITI.
This profile adds extension attributes (marked as “<new>”) to several existing resources.
The following text describes how the necessary structure and content of an imaging diagnostic report, as described in IHE RAD TF-1:56.4.1.2, would be encoded in FHIR.
DiagnosticReport.text contains the fully rendered human-readable form of the diagnostic report as described in 6.7.3.11. TOLINK
Narrative text in the patient section of the diagnostic report is a good candidate for auto-generation based on a subset of the coded content in the Patient resource, such as the sex and age of the patient. The name and medical record number are typically rendered into the top of the report as well.
Narrative text in the order section of the diagnostic report is a good candidate for auto-generation based on a subset of the coded content in the ServiceRequest resource. The ordered exam in ServiceRequest.code is usually rendered as a single line, perhaps based on the display value of the CodeableConcept. The Accession # and the ordering physician may also be rendered into the top of the report.
Note 1. The Indications and Clinical Questions, while captured at the time of the order and conveyed to the Report Creator in the referenced ServiceRequest, are typically rendered into the narrative in the History section of the report.
Note 2. The details in the Procedure section are pulled from the imaging Procedure Resource (which is what was performed based on patient needs) rather than the imaging ServiceRequest (which is what was ordered and sometimes driven by billing requirements) since the two do not always exactly match. Sometimes there is an effort to update the order to match the actual procedure; ideally if that does happen, it is best to do it before image interpretation to avoid the possibility that the ServiceRequest resource bundled with the DiagnosticReport is out of date with respect to the master copy of the reference. Sometimes the original order is cancelled and replaced by a new one in which case the Order reference/link is broken (but it is clear that something has changed). Resolving such issues is a workflow topic that is out of scope for this profile.
History shall reference resource items in <new> DiagnosticReport.patientHistory.
Notes: 1. While the specification requires the ability to include coded history information, it does not specify which or how much history information is encoded. Reports do not include the entire medical history available but rather include history details determined to be relevant to the study, usually by the imaging clinician,. Also, the details are coded as known to the imaging clinician at the time of interpretation; different information may be available when any given reader reads the report, but the report will reflect what was known at interpretation.
2. Often this history will include key details that also serve as the indication(s) for the imaging study. The information coded in the ServiceRequest.reason (See 6.7.3.2 Order) the definitive record in the indications, even if they are also duplicated here.
Condition shall be used to encode past diagnoses.
Observation shall be used to record relevant observations from the referring physician, nursing notes, past care, and past diagnostics such as anatomic histopathology or clinical laboratory result values.
Procedure shall be used to record past procedures performed on the patient such as knee surgery, an appendectomy, or spinal fusion.
FamilyMemberHistory shall be used to record a person’s relationship to the patient, along with the persons demographics, known conditions and procedures.
Narrative text in the history section of the diagnostic report is a good candidate for auto-generation based on the coded content in the referenced resources, however the process of selecting the relevant subset will likely require input from the imaging clinician or a sophisticated algorithm.
This narrative is where indications for the exam (if any) and clinical questions from the referring are included. Information for those two items will be accessed via the imaging ServiceRequest referenced in the .basedOn attribute rather than this .history attribute.
Each referenced Condition, Observation, Procedure, and FamilyMemberHistory has a .text attribute which can contain a brief description which may be assembled into the narrative text for the History section.
See also the discussion of .text usage in Section 6.7.3.11.1 Resources.text.
Procedure and Materials information shall be encoded in Procedure resource(s) referenced in a <new> DiagnosticReport.procedure attribute.
Notes: The DiagnosticReport.procedure attribute mirrors the .specimen attribute to describe how the data being reported was obtained and prepared.
Procedure resources describe a procedure that was performed. They provide details about technique and execution using clinical imaging language and codes and are created using information from the modality. In contrast, the ServiceRequest resource describes the order using orderable language and codes, which are typically more general and billing-oriented, and is created using information from the order placer. Further, the ImagingStudy resource describes and provides links for the actual Study data produced by the procedure(s), and is referenced from DiagnosticReport.study.
In the large majority of cases, one report will correspond to one study comprised of one procedure. Some studies do involve multiple procedures, e.g. a cardiac stress-rest workup, so systems shall be prepared to handle multiple procedures.
Procedure likely needs more profiling for imaging workflow and record-keeping, however that is out of scope for this Diagnostic Report Profile, and would be better addressed in concert with profiling imaging ServiceRequest. Until it is fully profiled, the current practice of user-generated text in the Procedure section of the DiagnosticReport.presentedForm will need to serve.
Narrative text in the procedure section of the diagnostic report is a good candidate for auto-generation, since it involves little to no interpretation. The text may be available in Procedure.text, which in turn would be based on a subset of the coded content in the referenced resource(s), usually the modality, date, procedure type, and details such as technique, pulse sequences, contrast usage, radiation dose, and generated images/views. The content of the Procedure resource likely originated from the image header, MPPS, RDSR, and performed procedure protocols.
During the imaging procedure, Observations might be created to capture things like nursing notes or technologist observations. Those would be associated with the Encounter for the imaging Procedure. Conveying those to the radiologist as inputs for interpretation is not addressed here since this profile is about encoding the resulting report. Future work on reporting workflow and managing inputs to the radiologist could address this.
Comparison studies shall be encoded in ImagingStudy resources referenced from a <new> DiagnosticReport.comparison attribute.
This serves as the “library” of studies the imaging clinician took into consideration. Actual comparison observations, both new comparative statements and cited old statements from the prior study, are encoded below with the findings.
Narrative text in the comparison section of the diagnostic report is a good candidate for auto-generation based on enumerating the coded content in the referenced resources, usually the modality, date, and procedure type.
Implementations are permitted to create reports where none of the findings in the narrative are encoded. Findings that are encoded shall use Observation resources referenced from DiagnosticReport.result. Implementations shall be capable of creating at least one Finding encoded as an Observation and referencing it from DiagnosticReport.result.
The following metadata shall be populated in the Observation (despite being referenced, or implicit, in the DiagnosticReport). One reason for this is to facilitate usage of the Observation resources beyond the direct context of the parent DiagnosticReport. For example, to perform Observation-level queries.
Observation.subject shall reference the imaged Patient.
Observation.basedOn shall reference the imaging ServiceRequest
Observation.encounter, if present, shall reference the imaging procedure Encounter.
Observation.partOf shall reference the interpreted ImagingStudy
Observation.category shall use the value “imaging”
Observation.status shall use “final” for observations in the final report.
The scope and complexity of report findings can vary significantly.
NOTE TO IMPLEMENTERS: Further profiling of the Findings section is deferred to future work.
As a strategic scoping decision of this profile, the use cases focus on subsequent usage of imaging reports by referring physicians and patients, and clinical pathway automation such as recommendation follow-up, critical finding tracking, and clinical decision support for referring physicians. Those use cases depend primarily on the Impression and Recommendation sections which are the primary interest for referring clinicians. The imaging clinician has summarized all the most important clinical information in the Impression section where all conclusions and actionable findings should be represented.
Addressing the enormous range and variety of imaging findings will be a significant undertaking. One significant avenue for bringing structure to the problem will be exploring the use of CDE Sets, which are defined groups of common data elements (and values) for describing specific imaging findings.
Future work on Finding encoding will consider use cases centered on the interpretation process that leads to the report. This may bring together AI result review and transcoding, the IRA profile, selecting findings from prior reports for inclusion in the current report, using LLM technologies to compose and process blocks of text, and other automation functions for the imaging clinician. Such use cases will be helpful concrete drivers in resolving the many expected complexities. Such work will likely manifest in the form of a Findings Option to this Profile to avoid disrupting any existing implementations and data from this Trial Implementation draft of the IDR Profile.
Findings that the radiologist chose to include in the report, but which originated from AI models, will likely include related details in the metadata and/or provenance of that finding. Such details will be accessible to recipients of the report. Conversely, details about the reporting process, such as what AI models were or were not run, and what findings were not included in the report, may be documented by associated systems in relevant logs, but will not appear in directly in the report itself unless the radiologist chooses to include such details, for example by describing that in the Procedure/Technique section.
Implementations shall be able to create at least one Condition and reference it in the DiagnosticReport.conclusionCode.
The following bullets focus on impression statements as structured coded data. The Report Creator is responsible for distinguishing and encoding dictated impressions, recommendations, and communications.
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Condition.actionable <new> shall, if present, contain a code to indicate the degree to which the Impression finding is actionable. Codes may be drawn from the RadLex codes for the ACR Actionable Finding Categories described in IHE Results Distribution (RD):
(RID49480, RadLex, “Cat 1 Emergent Actionable Finding”) defined as requiring immediate medical attention within minutes.
(RID49481, RadLex, “Cat 2 Urgent Actionable Finding”) defined as requiring medical attention within hours.
(RID49482, RadLex, “Cat 3 Non-critical Actionable Finding”) defined as requiring medical attention within days to months.
(RID50261, RadLex, “Non-actionable”) defined as not requiring follow-up actions.
Note 1. The presence of a Recommendation for a given impression is an implicit indication that it is actionable. Having an explicit code can help with subsequent tracking and follow-up.
Note 2. Conversely, actionable findings do not always have a corresponding Recommendation. For example, an identified pneumothorax is a well-known entity to the referring clinician with standard actions to address it. The imaging clinician would be unlikely to re-iterate those actions in the report.
Note 3. Category 1 and Category 2 codes constitute “critical findings” which often result in direct Communications (see Section 6.7.3.9) due to the clinical urgency.
The narrative form of the Impression section is often directly dictated by the imaging clinician. Tools also exist that generate a draft of the Impression narrative based on the dictated Findings narrative. If the Impression narrative were built up from the coded Impression, the summary in Condition.text of each referenced Condition resource might be compiled into impression bullets sequenced according to the Condition.order.
In addition to rendering the Impression narrative as a section in the full report in the DiagnosticReport.text attribute, the Report Creator may also render the Impression narrative into DiagnosticReport.conclusion as a single markdown field. The Impression narrative may contain dictated text which goes beyond the semantics captured in the DiagnosticReport.conclusionCode references.
If/when one of these Conditions is added to the patient Problem List, either by the referring physician or because the Condition.verificationStatus is confirmed, that would likely create a new Condition resource that might point to the Impression Condition instance as Condition.evidence (or maybe the biopsy result instead). While the Problem List Condition instance would be updated over time, for example when the condition is abated, the Impression Condition persists as a medicolegal snapshot that is an integral component of the Report. If the Report is exported, that bundle would contain the Impression Condition at the time of the report, not any “current” version.
Recommendations, if any, shall be encoded as ServiceRequest, CommunicationRequest, or CarePlan resources referenced from the DiagnosticReport.recommendation attribute.
Recommendations for subsequent imaging, lab tests, or specialist consultations would be encoded as draft ServiceRequests. Recommendations for simpler communications would be encoded as draft CommunicationRequests.
These draft ServiceRequests and CommunicationRequests, when created, may omit various details that the imaging clinician would not know or would not be responsible for choosing. They are intended to serve as a skeleton that facilitates the referring provider adding any needed details and activating it as an order.
serviceRequest.status shall use the value draft (“The request has been created but is not yet complete or ready for action.”)
serviceRequest.intent shall use the value proposal (to leave it up to the referring physician) or plan (if the imaging clinician feels it would be inappropriate if the recommended action does not take place)
serviceRequest.reason may reference a Condition resource in the Impression when the recommendation was motivated by that specific impression. This serves both to justify the recommendation, and to associate the recommendation with the impression which can influence their presentation.
Note: To capture specific clinical/practice guidelines or literature citations that were applied in making the recommendation (e.g., the Fleischner Criteria for lung nodule follow-up), those can also be referenced from ServiceRequest.reason. In HL7 v2, the IHE Results Distribution (RD) Profile encoded this in OBX-15. Since there is not currently a PracticeGuideline resource, it would be necessary to create a DocumentReference resource for the relevant policy or guideline document.
ServiceRequest.occurrence supports encoding a Period, i.e., a time range. Per FHIR, the context of use will make it clear that one value from the period applies. To encode a recommendation that a follow-up scan take place 6-9 months from now, the Report Creator calculates a start date 6 months from the current date, and an end date 9 months from the current date.
ServiceRequest.performerType can be used to encode a referral to a particular type of specialist.
ServiceRequest.orderDetail can be used to further specify protocol parameters, acquisition technique, desired views, patient preparation, etc., as appropriate. Detailed guidance on this is beyond the scope of this profile.
There is idiosyncratic variation between specialties, regions, and facilities as to whether recommendations are presented in the impressions section or presented separately. Since the underlying encoding of a recommendation differs from an impression, this profile separates the two. Implementations may still choose to group the two together in the presented form based on configuration and customer preferences.
A recommendation is often directly associated with a specific impression. This may be expressed in the dictated text by following the impression with a recommendation before moving on to the next impression. The Report Creator is responsible for maintaining the order and relationships between impressions and recommendations.
The narrative form of the Recommendations may be directly dictated by the imaging clinician. Tools also exist that generate a draft of the Recommendation narrative based on the Impressions and associated guidelines. If the Recommendation narrative is built up from the coded Recommendation, the summary in ServiceRequest.text of each referenced ServiceRequest resource might be compiled into recommendation bullets.
Although this Profile facilitates machine-readable encoding of the potential ServiceRequests, the narrative Recommendation text may also include conditional logic, e.g., if A is true then procedure X is recommended; if B is true then procedure Y is recommended; else procedure Z is recommended. This profile does not yet model this logic in the coded recommendations; as a placeholder, the condition text could be included in ServiceRequest.note, but this does not support automated tooling. In this example scenario, all three procedures would be included as referenced ServiceRequest resources (with status = draft, as described above) and the referring physician would apply the logic in the narrative to decide which to activate (by setting the status to active), if any.
This information is included in the body of the report, in part for medicolegal purposes. If future HIT infrastructure handles tracking such communications directly in the EMR, the practice of using the diagnostic report to implement such accountability and tracking might change, but for now it is expected to persist.
This information may also support performance metrics such as the speed with which the Referring Physician is notified of key clinical results or other conformance to best practices for patient safety and quality of care.
The corresponding section narrative text may be created by concatenating the .text contents for each of the referenced Communication resources. This narrative often appears at the bottom of the report under the Impressions and Recommendations.
Signature of the report shall be encoded as a Provenance resource.
Provenance.target shall reference the DiagnosticReport resource. (TODO should it reference all the resources that would go in the bundle, or is there a more efficient way to do this? Need to list the other resources that were created as “components” of the report, but not everything that goes in the bundle. So the observations and conclusions would be referenced, but not the patient or servicerequest)
Provenance.signature.type shall have a value of ProofOfApproval.
Provenance.agent.who and Provenance.signature.who (or Provenance.signature.onBehalfOf) shall be compatible with the person identified in DiagnosticReport.resultsInterpreter. See also Section 6.7.3.0.
While the DiagnosticReport does not reference Provenance resources, such as the one containing the digital signature, the relevant Provenance resources may be obtained with a query like:
Relevant Provenance can also be included in the response bundle when querying the DiagnosticReport in the first place using _revinclude:
Note: Some resources include a .relevantHistory element that documents prior clinical states of the resource via references to prior corresponding Provenance resources. The “current” Provenance cannot be so referenced since it cannot exist until after the current version of this “target” resource has been created.
Narrative text for the signature typically appears at the bottom of the report text with a statement in a form similar to “This report was digitally signed by Dr. X at <time> on <date>”.
Preliminary (“unsigned”) reports may involve a DiagnosticReport resource being made available which references a DiagnosticReport.resultsInterpreter, but is not the target of a Provenance resource with a .signature.type of ProofOfApproval.
In the unprofiled DiagnosticReport resource, the signature appears to be implicit. It is left to receivers to presume that if the report status is final and there is an interpreter listed, that means that practitioner approved the content of the report at some point in time.
The fully rendered human-readable form of the diagnostic report shall be encoded in the DiagnosticReport.text attribute. This attribute establishes a robust baseline representation of the report content. Additional optional representations are described in 6.7.3.11.1.
Per the FHIR guidance for .text narrative attributes, the .text narrative should support human-consumption as a fallback from parsing the resource; structured data should not generally contain information of importance to human readers that is omitted from the narrative. Accordingly, to the extent that the DiagnosticReport attributes described in Sections 6.7.3.2 through 6.7.3.9 are present with content, corresponding sections shall be present in the .text narrative.
Note 1. As a Narrative attribute, the content of .text is encoded in XHTML with additional FHIR constraints.
Note 2. The IHE Interactive Multimedia Report (IMR) Profile also constrains the content of the diagnostic report.
Sections shall be defined using <div> tags.
Each <div> tag shall have an ‘id’ attribute with a unique value assigned to the section.
Each <div> tag shall have a ‘class’ attribute with a code drawn from Table 6.7.3.11-1, and formatted as <coding system>|<code value>. This class code facilitates extraction of section text by report consumers.
Each <div> section shall contain a human readable title reflecting the code meaning for the section. The title may be localized and/or translated. The title may be enclosed in a header tag.
Each <div> section may contain HTML 4.0 Text, List or Table elements to organize content within the section
Each <div> section may contain the ‘narrativeLink’ or ‘originalText’ extension to link between data and narrative text. See https://hl7.org/fhir/R5/narrative.html#linking for details and an example.
See Figure 6.7.3.11-1 for an example of the use of <div> tags that shows two sections, one for Finding and one for Impression. The Finding section uses simple paragraph tags <p> to separate multiple contents. The Impression section uses an unordered list. This is not an example of a full report.
"text" : {
"status" : "generated",
"div" : "\<div xmlns=\\http://www.w3.org/1999/xhtml\\\>
\<div id=\\111\\ class=\\http://loinc.org\|59776-5\\\>
\<h2\>Findings:\</h2\>
The imaged portion of a thyroid gland is unremarkable. Prominent or
mildly enlarged mediastinal and bilateral hilar lymph nodes measure up
to 1.2 x 0.8 cm in the right paratracheal station (2:12) , 2.3 x 1.4
cm in the subcarinal station (2:18), and 1.4 x 0.9 cm in the right
hilar stations (2:16). No significant axillary lymphadenopathy is
detected. The esophagus is unremarkable. The thoracic aorta is normal
in caliber with a typical 3 vessel takeoff from the arch. The
pulmonary arterial trunk is normal in caliber. The heart is normal in
size without pericardial effusion.
\<p/\>
Within the pulmonary parenchyma, there is diffuse peribronchovascular
nodular and ground-glass opacities becoming confluent in the right
middle (601:52) and left upper (601:65) and lower lobes (601:72)
consistent with multifocal pneumonia. There is a small left and trace
right pleural effusion. No pneumothorax is present. There are no
suspicious masses or pleural abnormalities.
\<p/\>
…
\</div\>
\<div id=\\222\\ class=\\http://loinc.org\|19005-8\\\>
\<h2\>Impression:\</h2\>
\<ul\>
\<li\>Multifocal pneumonia involving the right middle, left upper and
left lower lobes with small left and trace right pleural
effusions.\</li\>
\<li\>Central mediastinal lymphadenopathy is likely reactive.\</li\>
\</ul\>
\</div\>
\</div\>"
},
Figure 6.7.3.11-1: <div> Section Example
Per FHIR guidance, all coded content of the diagnostic report that is relevant to a human reader should be present in the .text rendering.
The .text may also contain additional information which is not yet modelled in the coded form of the report. Some practices include links or references at the bottom of the report to educational material that may be helpful to the patient and/or referring physician to understand the impressions and/or recommendations.
Table 6.7.3.11-1: Section Codes
|
|
|
|
|---|---|---|---|
| 55115-0 | LN | Order | |
| 11329-0 | LN | History | |
| 55111-9 | LN | Procedure | |
| 18834-2 | LN | Comparison | |
| 59776-5 | LN | Findings | |
| 19005-8 | LN | Impression | |
| 18783-1 | LN | Recommendation | |
| 73568-8 | LN | Communication | This code is defined as communication of critical findings. A more general code may be needed since some communications do not involve critical findings. |
Additional renderings of the report in other formats such as PDF, HTML, or RTF, may be included as Attachments under .presentedForm. The .presentedForm.contentType shall contain a MIME code indicating the format of the content.
Since additional renderings are optional, DiagnosticReport consumers may
wish to refer to the .text rendering first. If present, renderings in
.presentedForm are typically targeted at the human readers (physicians,
patients), and the Report Creator may generate and include them to
address some of the different roles and goals described in RAD TF-1:
56.4.2.3 Use Case #3: Report Presentation. A .presentedForm may also be
encoded in HTML, which may permit more sophisticated renderings than
what is in .text, which is more constrained.
The additional renderings may contain graphical embellishments and/or improved formatting for better readability, but should not introduce clinical semantic content that is not present in the .text rendering.
It is recommended that the Attachment.title for each presented form
attachment be populated to facilitate the recipient being able to
distinguish between multiple presented forms and select an appropriate
one.
In addition to the rendered report in .text, and the presented form in .presentedForm, the Report Creator may choose to reference Composition resources in DiagnosticReport.composition to provide additional arrangements and renderings of the imaging report content. See RAD TF-1: 56.4.1.4 for further discussion of Composition.
Every FHIR Resource, being a child of the DomainResource, includes an optional .text attribute which, if present, contains a text summary of that resource instance for human interpretation. In the context of the imaging diagnostic report, these can be useful components for the construction of the human-readable form of the entire report.
Each ImagingStudy resource referenced in DiagnosticReport.comparison could have a one-line description of the study in ImagingStudy.text. Each Observation resource referenced in DiagnosticReport.results could have a brief text rendering of the observation in Observation.text.
As noted above, many of these pieces of narrative text are good candidates to be generated automatically from the coded content of the resource itself. Some report consumer applications will sometimes find the .text attributes a useful source of text for certain purposes, such as presenting a specific component of the report, or populating part of an HL7 V2 message segment.
The .text.status is required to be present and contains codes that describe the extent to which the semantic content of .text covers or exceeds the coded content of the resource. See https://www.hl7.org/fhir/R5/valueset-narrative-status.html
For resources, such as Patient, that are used widely beyond the scope of the diagnostic report, it the content of .text may or may not be well suited to direct copying or concatenation without some processing.
The DiagnosticReport resource, like most FHIR resources, encodes references to other associated resources. Handling collections of related resources is typically done with the Bundle resource using one of several bundle types and handling patterns.
As shown in the RAD-141 (Store Multimedia Report) transaction, when the report is initially created and stored, a transaction bundle (Bundle.type=transaction) is used to POST the newly created resources (DiagnosticReport, ImagingSelection, etc) as an integral set to be processed together and created on the server. For these new reporting resources, the Report Creator is typically the “source of truth”; i.e. the information it provides is definitive. Other resources are referenced by the DiagnosticReport but already existed prior to reporting; for example, the Patient that is the .subject, or the Practitioner that is the .resultsInterpreter. These are not expected to be in the transaction bundle during creation since they do not need to be created and other systems are the source of truth for those resources. Some resources, such as the ServiceRequest referenced in .basedOn and the ImagingStudy referenced in .study, are in a grey zone where they might typically be expected to exist prior to creation of the report but there may be situations where they are being “backfilled” by the Report Creator. In such cases, they may be included in the transaction bundle to be created conditionally as indicated by the Bundle.entry.request.ifNoneExist element.
As shown in the RAD-143 (Find Multimedia Report) transaction, when querying for a report, a searchset bundle (Bundle.type=searchset) is returned from the query. By default, the bundle contains matching DiagnosticReport resources and no referenced resources. The _include and _revinclude parameters can be used to have the searchset bundle in the response also contain other referenced resources. (See https://hl7.org/fhir/search.html#include).
Although out of scope for this profile, a future Export Imaging Diagnostic Report transaction may be created to handle the need to send DiagnosticReport resources to systems that will not necessarily have access to all the resources referenced in the DiagnosticReport (e.g., because the recipient is outside the IT boundary of the sender). That transaction will describe a push transaction that includes a “full set” of referenced resources in the message bundle.
These examples were prepared in support of the Imaging Diagnostic Report (IDR) Profile. TOLINK See Section 6.7.3 Imaging Diagnostic Report Encodings for the encoding specifications.
This appendix provides some examples of report content, followed by some examples of encodings. This is a limited set of illustrative examples. Additional examples may be available in IHE Connectathons.
The following bullets provide a sample of content typical of order descriptions in an imaging report.
CT Sinus w/o Contrast
MRI Brain with and without Contrast
MRI Left Shoulder
MG of the Screening (Bilateral) <sic; likely composed using a “MODALITY of the BODY PART” template>
PET/CT of the Skull Base To Mid-Thigh
US Guided Left Knee Injection
MRI Right Hip Arthrogram Including Cartigram Study
XR Chest 1 View
The following bullets provide a sample of content typical to history descriptions in an imaging report.
Memory loss, 2 weeks history of dysbalance and lethargy
Right arm weakness; Difficulty expressing thoughts in writing beginning about 4-5 months ago.
Work related injury on September 21, 2015, assess for traumatic tear left rotator cuff with superior shoulder pain and weakness.
24M with stent placement in the left main bronchus presents with right sided chest pain since 9am
A 52-year-old with hemoptysis. Right middle and lower lung zone consolidation. Please evaluate.
Spiculated right upper lobe lesion. The patient declined biopsy for follow-up. If increase in size would consent to biopsy.
Sinusitis.
The following bullets provide a sample of content typical to procedure descriptions in an imaging report.
Axial PD FS, coronal PD FS and PD, sagittal T1 and PD FS imaging is performed through the left shoulder without contrast.
Sagittal and axial T1-weighted images, axial FLAIR images, axial diffusion weighted sequences, axial T2-weighted images and coronal gradient echo sequences of the brain were obtained. Following gadolinium administration axial and coronal T1-weighted images were obtained.
Thin slice axial images through the paranasal sinuses were obtained and reconstructed in the coronal and sagittal planes.
After intraarticular injection of diluted gadolinium in saline, axial T1 fat-sat, axial PD fat-sat, coronal T1 fat-sat, sagittal T1 fat-sat, axial oblique PD fat-sat, and coronal bilateral PD fat-sat images were obtained. This was followed by multiple acquisitions in the coronal and sagittal plane sequentially carried out with post processing and color mapping performed in order to obtain a T2 mapping cartigram study.
Agents: F-18 fluorodeoxyglucose. Dose: 17.2 millicuries IV. Prior to the administration of the radiotracer, a fingerstick blood glucose level was drawn, measured as 121 mg/dL. CT images for attenuation correction and anatomic localization followed by PET images from the skull base to the thighs were obtained.
A PET CT scan was performed from the level of the vertex of the skull to the proximal thighs following the administration of 18.6 mCi of FDG intravenously.
CT scan of the abdomen and pelvis was obtained with intravenous and without enteric contrast material. Coronal and sagittal reformats were provided. Dose reduction technique: The CT scan was performed using appropriate/available dose optimization/reduction techniques.
CT angiographic examinations of the head and neck were obtained utilizing 75 cc Isovue 370 intravenous contrast. Multiplanar MIP and 3D reformatted images were also created and reviewed. Stenosis measurements were performed based on NASCET criteria. CT scan performed using appropriate/available dose optimization/reduction techniques.
Head CT without intravenous contrast. Axial images through the brain were acquired from skull base to the vertex with 5 mm slice thickness. Images were reviewed in brain, subdural and bone window settings.
Single AP view of the chest
The following bullets provide a sample of content typical to comparison descriptions in an imaging report.
CXR from mm/dd/yyyy, CT Chest from mm/dd/yyyy (two weeks prior)
CT-PE of July 18, 2012 and limited CT chest from the declined biopsy of September 10, 2012.
Left knee ultrasound DATE. Left knee radiographs DATE.
Multiple, last dated August 8, 2023.
No previous exams are available for comparison.
None available.
None.
The following bullets provide a sample of content typical to findings in an imaging report. Many of these examples are organized as sets of related findings.
Finding set (MRI Cervical Spine)
The cervical cord appears normal in its size and signal characteristics.
The C2-3 and C3-4 discs are degenerated.
There is some mild bulging of the C3-4 disc. Neither level demonstrates central or neural foraminal narrowing.
There has been prior fusion from C4 through C7 in good alignment and position. An anterior screw and plate device is present.
At C4-5 and C5-6 there is no recurrent central or neural foraminal narrowing.
At C6-7 there is mild bilateral bony neural foraminal narrowing without central canal compromise.
The C7-T1 level appears unremarkable.
Finding Set (PET-CT)
A right lower breast mass is seen measuring approximately 6.2 x 1.6 cm in transverse dimension with SUV max measuring up to 4.2. The patient has had prior bilateral axillary node dissections. There is no current adenopathy in the axilla bilaterally by size criteria or metabolic activity. There is no adenopathy in the mediastinum or hilum similarly.
No pulmonary nodules or masses are identified. However, moderate right and small left perfusions are seen with low-level metabolism, SUV max measuring up to 3.0.
Diffuse thoracic esophageal hypermetabolism is noted.
There is a non-specific subpleural nodule in the right lower lobe which measures 2mm in diameter (Se 3, Im 72).
A smaller enhancing extra-axial mass more suggestive of atypical meningioma is seen overlying the right mid temporal lobe measuring 1.3 x 0.6 CM. (Axial series 12 image 26).
There is no significant end vessel ischemic small vessel disease.
There is no acute infarct seen. No intracranial hemorrhage is recognized.
MUSCLES AND TENDONS: The gluteal tendons are intact. The hamstring tendon origins are intact.
No compressive mass within the carpal tunnel.
Moderate extensor carpi ulnaris tendinosis. There is fluid reflective of tenosynovitis in the second and third extensor compartments as well along the region of the extensor digitorum tendons.
Moderate amount of fluid in the radiocarpal and midcarpal wrist compartments.
Mild dorsal angulation of the distal radius reflective of the fracture.
Evidence of edema in the central and volar aspect of the ligament. Edema extends into the volar radiocarpal ligaments. The pattern is reflective of a volar injury and partial-thickness tear in this region. There is no complete tear. There is no DISI deformity.
The following bullets provide a sample of content typical to impressions in an imaging report.
In some cases, a set of impressions for a particular type of exam are provided as a group to get a sense of the ordering and grouping patterns. Some impression sentences encompass multiple Conditions. Some impressions are shown broken down into more codable components.
When the imaging clinician has interposed a recommendation amongst the impressions, it has been highlighted here {underlined between braces}.
As an exercise to explore the suitability of the specification, a sample encoding [shown in square brackets] is provided for some impressions. Also, the encodings do not always capture 100% of the intended semantics and nuances of the radiologist.
Findings suggesting left peripheral lung base pulmonary infarct.
Impression Set (Abdomen US)
Fatty infiltration of the liver.
Small left pleural effusion.
Distended inferior vena cava and hepatic veins, findings consistent with congestive heart failure.
Impression Set (XR Foot, Ankle, Tibia/Fibula, Knee)
Acute nondisplaced fractures of the proximal tibia and fibula.
Acute fracture of the distal fibular diaphysis.
Intact intramedullary nail fixation hardware.
Impression Set (MRI Hip)
Moderate right hip osteoarthritis, with labral tearing and para labral cyst formation.
[Condition.code= (396275006, SCT, “Osteoarthritis”), .bodyStructure.includedStructure.structure= (24136001, SCT, “Hip joint”), .bodyStructure.includedStructure.laterality=right, .severity=moderate]
[Condition.code=(202336002, SCT, “Acetabular labrum tear”), .bodyStructure.includedStructure.structure= (182439007, SCT, “Acetabular labrum”), .bodyStructure.includedStructure.laterality=right]
[Need code for para labral cyst, .bodyStructure.includedStructure.structure= (182439007, SCT, “Acetabular labrum”), .bodyStructure.includedStructure.laterality=right]
Chronic partial-thickness tears of the gluteus minimus and medius with small overlying greater trochanteric bursal fluid.
Impression Set (CT Neck, Chest, Abdomen/Pelvis)
No acute abnormality in the neck, chest, abdomen, or pelvis. No pathologically enlarged lymph nodes.
Multiple peribronchial bilateral pulmonary nodules, measuring up to 5 mm in the left lower lobe, likely infectious/inflammatory.
No active GI bleed.
Mesenteric vessels are patent without evidence of end-organ ischemia.
Impression Set (MRI Brain, MRI Cervical Spine)
No evidence of acute infarction, hemorrhage, or a mass lesion. Chronic changes as described above.
A 1.1 cm focus of enhancement within the left parietal bone that does not demonstrate any cortical destruction or any other destructive features. There is a lucency at this site on the previously performed head CT. It is favored to represent a venous lake.
Congenitally small central canal from C3/C4 down to C5/C6 level.
Moderate to severe degenerative changes of the cervical spine as described above and summarized below.
At C3/C4, moderate central canal stenosis with flattening of the ventral surface of the cord. Moderate left neural foraminal stenosis.
At C4/C5, moderate central canal stenosis with flattening of the ventral surface of the cord. Moderate to severe left neural foraminal stenosis.
At C5/C6, moderate bilateral neural foraminal stenosis.
At C6/C7, moderate right neural foraminal stenosis.
Impression Set
Prominent bilobed paramedial extra-axial mass along the convexity centered at the level of the posterior frontal and anterior parietal lobes with prominent posterior dural tail and occlusion of the adjacent superior sagittal sinus. Prominent surrounding reactive edema, left greater than right. Mild lateral shift but no herniation. Smaller extra-axial mass overlying the right mid temporal lobe.
[Prominent bilobed (SHAPE) paramedial extra-axial (LOC) mass
along the convexity (LOC)
centered at the level of the posterior frontal and anterior parietal lobes (LOC)
with prominent posterior dural tail (SHAPE)
and occlusion of the adjacent superior sagittal sinus (LOC?).
Prominent surrounding reactive edema (RELATED CONDITION & LOC), left greater than right (SEVERITY?).
Mild lateral shift but
no herniation.
Smaller extra-axial mass (RELATED CONDITION & SHAPE)
overlying the right mid temporal lobe (LOC).]
Atypical meningioma including hemangiopericytoma or variant or malignant subsidence of meningioma. Other less likely considerations include extra-axial dural based metastasis, lymphoma and less likely solitary fibrous tumor.
Impression Set
There is mild supraspinatus tendinosis with minimal articular sided fraying of the distal tendon and a 3 mm low grade interstitial tear at the distal attachment site.
There is marrow edema within the distal clavicle. There is a small AC joint effusion with mild pericapsular edema. This may represent mild stress related change of the AC joint versus a grade 1 sprain of the AC joint. There is no elevation or fracture of the distal clavicle.
There is no occult fracture or bone contusion. No malalignment of the osseous structures.
The age of injury is indeterminate.
There is a metastasis located within the right temporal lobe surrounded by a moderate size area of vasogenic edema. {Further evaluation with an enhanced MRI examination of the brain is recommended.} There are large confluent right hilar/parahilar and mediastinal metastases located within the chest. There is a complete atelectasis/consolidation of the right upper lobe (drowned lung). There are numerous metastases located within the peripheral portions of both lungs. There are multiple hepatic metastases. Please see report.
Impression Set
Complete full-thickness disruption of the anterior cruciate ligament.
Associated osseous contusion of the lateral condylar patellar sulcus: Pivot shift injury.
Grade 1 MCL complex injury.
No other associated injury identified <How should we code negation when there is no concrete condition being negated?>
Impression Set
Hydrocephalus without evidence of obstructing mass lesion. Acute hydrocephalus cannot be excluded since there are no prior studies available for comparison. Extensive chronic white matter changes may mask transependymal CSF edema. {Correlate with short-term followup to exclude acute hydrocephalus. Correlate with clinical symptoms to exclude normal pressure hydrocephalus.}
Chronic white matter changes.
Cerebral atherosclerosis.
Impression Set
Markedly abnormal multifocal hypermetabolic predominantly osteosclerotic lesions scattered throughout the axial and proximal appendicular skeleton consistent with wide spread osseous metastases
Right lower breast mass that appears hypermetabolic. {Please correlate with mammography and consider biopsy if indicated.} Recurrent disease is a consideration.
Indeterminate bilateral pleural effusions and ascites with low-level metabolism. Consider thoracentesis and evaluation of fluid for malignancy if clinically indicated.
Diffuse thoracic esophageal uptake. This pattern can be seen in patients with esophagitis. Please correlate clinically.
Spiculated mass within the posterior segment of the right upper lobe has increased minimally in size from September 2012, now with maximal dimension of 2cm versus 1.6cm previously. Radiographic staging of this presumed malignancy is T1a N0. No new pulmonary nodules and no findings of metastatic disease.
Impression Set (CTA Chest)
Moderate pericardial effusion with apparent mass effect on the right ventricle, leftward bowing of the intraventricular septum, a contrast level within the IVC, and severe reflux of contrast into the hepatic veins and right lobe parenchyma are highly suggestive of tamponade physiology. Pericardial enhancement suggests pericarditis as etiology.
No aortic dissection or intramural hematoma.
Impression Set (Lung Cancer screening Chest CT)
Lung-RADS CATEGORY: 2/S. Multiple pulmonary nodules. The dominant solid nodule is located in the right middle lobe and has a mean size of 5 mm (series 3, image 285). The category-determining solid nodule has a very low likelihood of becoming a clinically active cancer, due to size and/or lack of growth.
There are potentially significant incidental finding(s): thyroid lesion, incompletely characterized by CT
{RECOMMENDATIONS: Continue annual Lung Cancer Screening Chest CT examination if patient meets eligibility criteria.}
{RECOMMENDATION FOR POTENTIALLY SIGNIFICANT INCIDENTAL FINDING: Thyroid ultrasound, unless recently obtained}
Explanation of the Lung-RADS CATEGORIES CAN BE FOUND AT: HTTP://healthcare.partners.org/lung/rads.pdf
A clinically significant result was communicated on 2/–/202x 10:08 PM, Message ID ——.
Unremarkable CT evaluation of the paranasal sinuses. No obstructive pathology is seen.
(Chest X-ray) No acute cardiopulmonary process.
(MRI Brain) No acute or subacute infarct, mass effect, or acute intracranial hemorrhage.
Impression Set (CT Head)
No acute intracranial findings.
Mild left parietal scalp swelling and contusion. No acute calvarial fracture.
Impression Set (Screening Mammogram)
No mammographic evidence of malignancy in either breast.
{Annual screening mammography is recommended.}
BI-RADS 1 NEGATIVE [(397140005, SCT, “Mammography assessment (Category 1) – Negative”)]
The patient will be notified of the results and recommendations.
Impression Set (OB US)
24 y.o. G3P2 at 21 weeks by 18 week ultrasound with reassuring fetal anatomic survey. Ms. X has a significant psychiatric history and is maintained on Lithium with good effect; she reports her mood is stable and she is in close contact with her psychiatrist. We reviewed the plan for a fetal echocardiogram and a referral was placed.
Worksheet finished by —- —–, sonographer on 1/–/202- 1:2-:5- PM.
No evidence of acetabular labral tear or detachment. There is no high-grade chondral loss or delamination.
Very dense breasts without comparison studies limiting sensitivity. Comparison to previous mammograms would be helpful to assure stability of dense parenchymal pattern.
No active disease in the chest.
The following bullets provide a sample of content typical to recommendations in an imaging report.
Referral to the DAP service is recommended. The lesion is amenable to CT guided biopsy.
Further evaluation with an enhanced MRI examination of the brain is recommended.
Recommend further evaluation with dedicated breast imaging at XXX Breast Imaging Center by calling xxx-xxx-xxxx to schedule an appointment.
Please correlate with mammography and consider biopsy if indicated.
Annual screening mammography is recommended.
Correlate with short-term followup to exclude acute hydrocephalus. Correlate with clinical symptoms to exclude normal pressure hydrocephalus.
Continue annual Lung Cancer Screening Chest CT examination if patient meets eligibility criteria
Recommendation for potentially significant incidental finding: Thyroid ultrasound, unless recently obtained
Recommend discussion of X with the patient.
The following bullets provide a sample of content typical to descriptions of communications in an imaging report.
Findings discussed with Dr. REFERRING at 1630 hrs
Telephone message was left at Dr. DAVID LIVESEY office at the time of dictation.
A clinically significant result was communicated on 2/19/2024 10:08 PM
A report viewer might offer to display studies used as comparisons in the report.
A clinical workstation might help the referring physican to place an order for the followup PET scan recommended in the report by the radiologist.
A clinical workstation might help the referring physician to identify current clinical guidelines applicable to the conclusions identified in the report.
IG © 2024+ IHE Radiology Technical Committee. Package ihe.rad.idr#0.0.1-current based on FHIR 6.0.0-ballot3. Generated 2025-09-14
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