Imaging report reflects the observations and interpretations of one or more imaging studies, contains elements such as the reason why the study is requested, relevant contextual medical information, the modality used to acquire images and its settings, procedures and body localisations that were used, a description of the observations and findings, exposure information, conclusion and advice.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

The author of the report.

Date and optionally time of authoring/issuing

Status of the report

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document (e.g. 18748-4 Diagnostic imaging study)

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the content of the document.

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. imaging study types, body regions, modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

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 document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Accession number - 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).

eHN Guideline IMG (v1.1): A.1.8.11

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

eHN Guideline IMG (v1.1): A.1.4

Imaging report structured body

Order Information (Imaging Result Report could respond to multiple orders).

eHN Guideline IMG (v1.1): A.2

Identifier(s) of the imaging service order.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested.

SNOMED CT

eHN Guideline IMG (v1.1): A.3.1, A3.2

Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.

eHN Guideline IMG (v1.1): A.3.3

This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.

eHN Guideline IMG (v1.1): A3.2?

Clinical findings and other observations (e.g., height and weights of the patient).

Conditions that may influence the service or result interpretation.

Medication administered before ordering the service specifically for this procedure.

List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).

Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).

Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.

HL7 sex-parameter-for-clinical-use

Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.

eHN Guideline IMG (v1.1): A.4

Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.

eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition

Examination report content.

eHN Guideline IMG (v1.1): A.5

Imaging modality (or modalities) used during imaging investigation (DICOM CID029).

DICOM Modality

eHN Guideline IMG (v1.1): A.5.1.1

All body parts investigated

eHN Guideline IMG (v1.1): A.5.1.6

Imaging procedure performed during imaging study.

eHN Guideline IMG (v1.1): A.5.1.2-A.5.1.9

Information about medications administered (contrast, sedation, stress agents, etc) during the procedure.

eHN Guideline IMG (v1.1): A.5.2

Adverse reactions manifested during imaging investigation.

eHN Guideline IMG (v1.1): A.5.3

Imaging report result data (report could consist of multiple observations)

eHN Guideline IMG (v1.1): A.5.4, A.5.4.1, A.5.4.3

A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.

eHN Guideline IMG (v1.1): A.5.5

Narrative description of the clinical conclusion (impression).

eHN Guideline IMG (v1.1): A.5.5.1

Condition or finding from imaging investigation.

eHN Guideline IMG (v1.1): A.5.5.2

Recommendation section for additional imaging tests or other actions

eHN Guideline IMG (v1.1): A.5.6

Narrative description of the recommended activities including additional test, medication etc.

eHN Guideline IMG (v1.1): A.5.6.1

A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.

eHN Guideline IMG (v1.1): A.5.6.2

Documentation (reference) of a prior Imaging Report to which the current images were compared.

eHN Guideline IMG (v1.1): A.7

Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

eHN Guideline IMG (v1.1): A.6

Report attachments

Imaging report reflects the observations and interpretations of one or more imaging studies, contains elements such as the reason why the study is requested, relevant contextual medical information, the modality used to acquire images and its settings, procedures and body localisations that were used, a description of the observations and findings, exposure information, conclusion and advice.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

The author of the report.

Date and optionally time of authoring/issuing

Status of the report

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document (e.g. 18748-4 Diagnostic imaging study)

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the content of the document.

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. imaging study types, body regions, modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

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 document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Accession number - 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).

eHN Guideline IMG (v1.1): A.1.8.11

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

eHN Guideline IMG (v1.1): A.1.4

Imaging report structured body

Order Information (Imaging Result Report could respond to multiple orders).

eHN Guideline IMG (v1.1): A.2

Identifier(s) of the imaging service order.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested.

SNOMED CT

eHN Guideline IMG (v1.1): A.3.1, A3.2

Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.

eHN Guideline IMG (v1.1): A.3.3

This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.

eHN Guideline IMG (v1.1): A3.2?

Clinical findings and other observations (e.g., height and weights of the patient).

Conditions that may influence the service or result interpretation.

Medication administered before ordering the service specifically for this procedure.

List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).

Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).

Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.

HL7 sex-parameter-for-clinical-use

Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.

eHN Guideline IMG (v1.1): A.4

Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.

eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition

Examination report content.

eHN Guideline IMG (v1.1): A.5

Imaging modality (or modalities) used during imaging investigation (DICOM CID029).

DICOM Modality

eHN Guideline IMG (v1.1): A.5.1.1

All body parts investigated

eHN Guideline IMG (v1.1): A.5.1.6

Imaging procedure performed during imaging study.

eHN Guideline IMG (v1.1): A.5.1.2-A.5.1.9

Information about medications administered (contrast, sedation, stress agents, etc) during the procedure.

eHN Guideline IMG (v1.1): A.5.2

Adverse reactions manifested during imaging investigation.

eHN Guideline IMG (v1.1): A.5.3

Imaging report result data (report could consist of multiple observations)

eHN Guideline IMG (v1.1): A.5.4, A.5.4.1, A.5.4.3

A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.

eHN Guideline IMG (v1.1): A.5.5

Narrative description of the clinical conclusion (impression).

eHN Guideline IMG (v1.1): A.5.5.1

Condition or finding from imaging investigation.

eHN Guideline IMG (v1.1): A.5.5.2

Recommendation section for additional imaging tests or other actions

eHN Guideline IMG (v1.1): A.5.6

Narrative description of the recommended activities including additional test, medication etc.

eHN Guideline IMG (v1.1): A.5.6.1

A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.

eHN Guideline IMG (v1.1): A.5.6.2

Documentation (reference) of a prior Imaging Report to which the current images were compared.

eHN Guideline IMG (v1.1): A.7

Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

eHN Guideline IMG (v1.1): A.6

Report attachments