HL7 Europe Imaging Report R4, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.1.1-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/imaging-r4/ and changes regularly. See the Directory of published versions

Example unstructured report

Unstructured report

This example addresses representing a imaging report that has the minimal amount of the structured data.

The structure of this report is illustrated in the figure below.

The report is represented as a DocumentReference resource following the profile UnstructuredDocumentReferenceEuImaging. It refers to a Patient and to an Organization resource that represents the custodian of the document.

The full resource is presented below. In this example the Patient and custodian Organization resources are included as contained resources.

<DocumentReference xmlns="http://hl7.org/fhir">
  <id value="UnstructuredReportExample"/>
  ...
  <language value="en"/>
  ...
  <contained>
    <Patient>
      <id value="PatientUnstructuredReport"/>
      <meta>
        <profile
                 value="http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core"/>
      </meta>
      <name>
        <use value="official"/>
        <text value="Jane Doe"/>
        <family value="Doe"/>
        <given value="Jane"/>
      </name>
      <birthDate value="1976-04-29"/>
    </Patient>
  </contained>
  <contained>
    <Organization>
      <id value="OrganizationUnstructuredReport"/>
      <meta>
        <profile
                 value="http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core"/>
      </meta>
      <name value="Rediologie Zentrum Bremen"/>
      <contact>
        <telecom>
          <system value="phone"/>
          <value value="0421 / 84 13 13 04"/>
        </telecom>
        <telecom>
          <system value="fax"/>
          <value value="0421 / 84 13 13 84"/>
        </telecom>
        <telecom>
          <system value="url"/>
          <value value="radiologiezentrum-bremen.de"/>
        </telecom>
        <address>
          <type value="physical"/>
          <text value="Schwachhauser Heerstr. 54, 28209 Bremen"/>
          <line value="Schwachhauser Heerstr. 54">
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-streetName">
              <valueString value="Schwachhauser Heerstr."/>
            </extension>
            <extension
                       url="http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-houseNumber">
              <valueString value="54"/>
            </extension>
          </line>
          <city value="Bremen"/>
          <postalCode value="28209"/>
        </address>
      </contact>
    </Organization>
  </contained>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality">
    <valueCodeableConcept>
      <coding>
        <system value="http://dicom.nema.org/resources/ontology/DCM"/>
        <code value="CT"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <identifier>
    <use value="official"/>
    <system value="urn:ietf:rfc:3986"/>
    <value value="http://unstructured-report.example.com"/>
  </identifier>
  <status value="current"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="18748-4"/>
      <display value="Diagnostic imaging study"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="urn:oid:1.3.6.1.4.1.19376.1.2.6.1"/>
      <code value="REPORTS"/>
      <display value="Reports"/>
    </coding>
  </category>
  <subject>
    <reference value="#PatientUnstructuredReport"/>
  </subject>
  <custodian>
    <reference value="#OrganizationUnstructuredReport"/>
  </custodian>
  <content>
    <attachment>
      <contentType value="application/pdf"/>
      <language value="de"/>
      <url value="./Binary/unstructured-pdf"/>
      <creation value="2024-01-01T00:00:00Z"/>
    </attachment>
  </content>
</DocumentReference>