A.1 - EHDS refined base model for Imaging Report header data elements

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Author by whom the document was/were authored. Multiple authors could be provided.

Attester who validated the document. Mulitple attesters could be provided.

The person taking responsibility for the medical content of the document

Data relevent to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Unique global identifier(s) that identifies an imaging study upon which the imaging report is based.An identifier that links an imaging report to one or more imaging studies. This element is relevant for the interactive selection of the available studies.

OID

This is an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

Entire report as issued pdf format recommended

Media attachments.

A.1 - EHDS refined base model for Imaging Report header data elements

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Author by whom the document was/were authored. Multiple authors could be provided.

Attester who validated the document. Mulitple attesters could be provided.

The person taking responsibility for the medical content of the document

Data relevent to document type and its content for administrative and searching purposes.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Unique global identifier(s) that identifies an imaging study upon which the imaging report is based.An identifier that links an imaging report to one or more imaging studies. This element is relevant for the interactive selection of the available studies.

OID

This is an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

Entire report as issued pdf format recommended

Media attachments.

A.1 - EHDS refined base model for Imaging Report header data elements

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Author by whom the document was/were authored. Multiple authors could be provided.

Attester who validated the document. Mulitple attesters could be provided.

The person taking responsibility for the medical content of the document

Data relevent to document type and its content for administrative and searching purposes.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Unique global identifier(s) that identifies an imaging study upon which the imaging report is based.An identifier that links an imaging report to one or more imaging studies. This element is relevant for the interactive selection of the available studies.

OID

This is an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

Entire report as issued pdf format recommended

Media attachments.