Generated Narrative: StructureDefinition EHDSImagingReportObligations Name Flags Card. Type Description & Constraints EHDSImagingReport 0..* EHDSImagingReport Imaging report model #xD; header O 1..1 Base Imaging report header Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; subject O 1..1 EHDSPatient Patient/subject information Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; identifier O 1..* Identifier Unique identifier of the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; author[x] O 1..* EHDSHealthProfessional, EHDSOrganisation, EHDSDevice The author of the report. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; date O 1..1 dateTime Date of finalising/issuing the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; status O 1..1 CodeableConcept Status of the report Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; language O 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag. Obligations Actor SHALL:able-to-populate Producer #xD; documentType O 1..1 CodeableConcept Type of document (e.g. 18748-4 Diagnostic imaging study) Obligations Actor SHALL:able-to-populate Producer #xD; documentTitle O 1..1 string 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' Obligations Actor SHALL:able-to-populate Producer #xD; period O 0..1 Period Time of service that is being documented Obligations Actor SHOULD:able-to-populate Producer #xD; attestation O 0..* Base Document attestation details Obligations Actor SHALL:able-to-populate Producer #xD; attester[x] O 1..1 EHDSHealthProfessional, EHDSDevice Attester who validated the document Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; datetime O 1..1 dateTime Date and time of the approval of the document by Attester Obligations Actor SHALL:able-to-populate Producer #xD; legalAuthentication O 0..* Base Document legal authentication details Obligations Actor SHALL:able-to-populate Producer #xD; legalAuthenticator[x] O 1..1 EHDSHealthProfessional, EHDSOrganisation The person or organisation taking responsibility for the content of the document. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; datetime O 1..1 dateTime Date and time when the document was authorised Obligations Actor SHALL:able-to-populate Producer #xD; eventType O 0..* CodeableConcept 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. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; serviceSpecialty O 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty) Obligations Actor SHOULD:process Consumer #xD; custodian O 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; accessionNumber O Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; intendedRecipient[x] O Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; presentedForm O 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; body O 0..1 Base Imaging report structured body Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; orderInformation O 0..* Base Order Information (Imaging Result Report could respond to multiple orders). Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; orderId O 1..* Identifier Identifier(s) of the imaging service order. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; orderReason[x] O 0..* CodeableConcept, EHDSCondition, EHDSObservation, string An explanation or justification for why this service is being requested. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; clinicalQuestion O 0..1 string Specification of clinical question (goal of the investigation) to be answered by the imaging investigation. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; supportingInformation O 0..1 Base Additional clinical information about the patient or specimen that may affect service delivery or interpretation (additional types of information may be allowed in implementations). Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; specimen O 0..* EHDSSpecimen Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; exposureInformation O 0..1 string Information on total exposure to ionising radiation. This information is required by regulations in several EU countries. Obligations Actor SHOULD:able-to-populate Producer #xD; examinationReport O 1..1 Base Examination report content. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; modality O 1..* CodeableConcept Imaging modality (or modalities) used during imaging investigation (DICOM CID029). Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; bodySite O 0..* EHDSBodyStructure All body parts investigated Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; imagingProcedures O 0..* EHDSProcedure Imaging procedure performed during imaging study. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; medicationAdministration O 0..* EHDSMedicationAdministration Information about medications administered (contrast, sedation, stress agents, etc) during the procedure. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; adverseReaction O 0..* EHDSAllergyIntolerance Adverse reactions manifested during imaging investigation. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; results[x] O 0..* EHDSObservation, string Imaging report result data (report could consist of multiple observations) Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; conclusion O 0..1 Base A concise and clinically contextualised summary including interpretation/impression of the diagnostic report. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; impression O 1..1 string Narrative description of the clinical conclusion (impression). Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; conditionOrFinding[x] O 0..* EHDSCondition, EHDSObservation Condition or finding from imaging investigation. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; recommendation O 0..1 Base Recommendation section for additional imaging tests or other actions Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; description O 1..1 string Narrative description of the recommended activities including additional test, medication etc. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; carePlan O 0..* EHDSCarePlan A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; comparisonStudy O 0..* EHDSImagingReport Documentation (reference) of a prior Imaging Report to which the current images were compared. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; dicomStudyMetadata O 0..* EHDSImagingStudy 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. Obligations Actor SHALL:able-to-populate Producer SHOULD:process Consumer #xD; attachments O 0..* EHDSAttachment Report attachments Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; Documentation for this format
Obligations for the logical model of imaging report.
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.
Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Date and optionally time of authoring/issuing
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.
Type of document (e.g. 18748-4 Diagnostic imaging study)
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
Date and time of the approval of the document by Attester
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.
Additional details about where the content was created (e.g. clinical specialty)
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).
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
Order Information (Imaging Result Report could respond to multiple orders).
Identifier(s) of the imaging service order.
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.
Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.
Additional clinical information about the patient or specimen that may affect service delivery or interpretation (additional types of information may be allowed in implementations).
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.
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.
Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.
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
Imaging modality (or modalities) used during imaging investigation (DICOM CID029).
Imaging procedure performed during imaging study.
Information about medications administered (contrast, sedation, stress agents, etc) during the procedure.
Adverse reactions manifested during imaging investigation.
Imaging report result data (report could consist of multiple observations)
A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.
Narrative description of the clinical conclusion (impression).
Condition or finding from imaging investigation.
Recommendation section for additional imaging tests or other actions
Narrative description of the recommended activities including additional test, medication etc.
A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.
Documentation (reference) of a prior Imaging Report to which the current images were compared.
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.