Generated Narrative: StructureDefinition EHDSImagingReport Name Flags Card. Type Description & Constraints <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport" title="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.">EHDSImagingReport 0..* EHDSDocument Imaging report model Elements defined in Ancestors:header, header, presentedForm #xD; header 1..1 Base Imaging report header #xD; author[x] 1..* EHDSHealthProfessional, EHDSOrganisation, EHDSDevice The author of the report. #xD; status 1..1 CodeableConcept Status of the report #xD; documentType 1..1 CodeableConcept Type of document (e.g. 18748-4 Diagnostic imaging study) #xD; eventType 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. #xD; accessionNumber 0..* Identifier 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). #xD; intendedRecipient[x] 0..* 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 #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; intendedRecipientEHDSDevice EHDSDevice #xD; body 0..1 Base Imaging report structured body #xD; orderInformation 0..* Base Order Information (Imaging Result Report could respond to multiple orders). #xD; orderId 1..* Identifier Identifier(s) of the imaging service order. #xD; orderDateAndTime 0..1 dateTime Date and time of the order placement. #xD; orderPlacer[x] 0..1 The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself. #xD; orderPlacerEHDSHealthProfessional EHDSHealthProfessional #xD; orderPlacerEHDSOrganisation EHDSOrganisation #xD; orderPlacerEHDSPatient EHDSPatient #xD; orderReason[x] 0..* An explanation or justification for why this service is being requested. Binding Description: (preferred): SNOMED CT #xD; orderReasonCodeableConcept CodeableConcept #xD; orderReasonEHDSCondition EHDSCondition #xD; orderReasonEHDSObservation EHDSObservation #xD; orderReasonString string #xD; clinicalQuestion 0..1 string Specification of clinical question (goal of the investigation) to be answered by the imaging investigation. #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.body.supportingInformation" title="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.">supportingInformation 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). #xD; observation 0..* EHDSObservation Clinical findings and other observations (e.g., height and weights of the patient). #xD; condition 0..* EHDSCondition Conditions that may influence the service or result interpretation. #xD; priorMedicationAdministration 0..* EHDSMedicationAdministration Medication administered before ordering the service specifically for this procedure. #xD; device 0..* EHDSDeviceUse List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants). #xD; pregnancyStatus 0..1 EHDSCurrentPregnancy Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown). #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.body.supportingInformation.sexForClinicalUse" title="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.">sexForClinicalUse 0..1 CodeableConcept 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. Binding Description: (preferred): HL7 sex-parameter-for-clinical-use #xD; specimen 0..* EHDSSpecimen Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes. #xD; exposureInformation 0..1 string Information on total exposure to ionising radiation. This information is required by regulations in several EU countries. #xD; examinationReport 1..1 Base Examination report content. #xD; modality 1..* CodeableConcept Imaging modality (or modalities) used during imaging investigation (DICOM CID029). Binding Description: (preferred): DICOM Modality #xD; bodySite 0..* EHDSBodyStructure All body parts investigated #xD; imagingProcedures 0..* EHDSProcedure Imaging procedure performed during imaging study. #xD; medicationAdministration 0..* EHDSMedicationAdministration Information about medications administered (contrast, sedation, stress agents, etc) during the procedure. #xD; adverseReaction 0..* EHDSAllergyIntolerance Adverse reactions manifested during imaging investigation. #xD; results[x] 0..* Imaging report result data (report could consist of multiple observations) #xD; resultsEHDSObservation EHDSObservation #xD; resultsString string #xD; conclusion 0..1 Base A concise and clinically contextualised summary including interpretation/impression of the diagnostic report. #xD; impression 1..1 string Narrative description of the clinical conclusion (impression). #xD; conditionOrFinding[x] 0..* Condition or finding from imaging investigation. #xD; conditionOrFindingEHDSCondition EHDSCondition #xD; conditionOrFindingEHDSObservation EHDSObservation #xD; recommendation 0..1 Base Recommendation section for additional imaging tests or other actions #xD; description 1..1 string Narrative description of the recommended activities including additional test, medication etc. #xD; carePlan 0..* EHDSCarePlan A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan. #xD; comparisonStudy 0..* EHDSImagingReport Documentation (reference) of a prior Imaging Report to which the current images were compared. #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.dicomStudyMetadata" title="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.">dicomStudyMetadata 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. #xD; attachments 0..* EHDSAttachment Report attachments #xD; Documentation for this format
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 medical content of the document (typically the person who signs it)
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.