Bundle: Imaging Report semi-structured - EU Imaging Report R5 v1.0.0-ballot

EU Imaging Report R5
1.0.0-ballot - ci-build 150

EU Imaging Report R5, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/imaging-r5/ and changes regularly. See the Directory of published versions

Example Bundle: Bundle: Imaging Report semi-structured

Document Details

Language: en

Profile: Bundle: Imaging Report

Final Document at 2025-05-08 by Dr. Lucas Gasenzer(official): Radiologist at Radiology Zentrum Bremen, Radiology Zentrum Bremen for Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29

Document Subject

Language: en

Profile: Patient (EU core)

Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29

Document Content

MR Knee — final report.

Patient	Frau GuteFrage Test-Schusti, born 1976-04-29
Author	Dr. Lucas Gasenzer (Radiologist)
Organization	Radiology Zentrum Bremen
Report date	2025-05-08
Report identifier	o32u4js8492ff

Imaging Study

ImagingStudy:	identifier = Study Instance UID: DUI#urn:oid:1.2.276.2000010.784732; status = available; modality = Magnetic Resonance; started = 2025-04-29
ImagingStudy:	identifier = Study Instance UID: DUI#urn:oid:1.2.276.2000010.784733; status = available; modality = Magnetic Resonance; started = 2025-04-29

Order

Nil known

History

Nil known

Procedure

Unavailable

Comparison

Unavailable

Findings

Note:	Linker Fuß: Allenfalls geringe Abflachung des Fußgewölbes und normale Dicke der Plantarfaszie. Regelrechte Artikulation im Rückfuß, Mittelfuß und Vorfußes. Im Großzehengrundgelenk deutliche Verschmälerung des Gelenkspaltes und Ausbildung von subchondralen Geröllzysten sowie deutliche postoperative Veränderungen nach Umstellungsosteotomie. Die Beuge- und Strecksehnen sind intakt.
Note:	Rechter Fuß: Analog zur Gegenseite zeigt sich eine allenfalls geringe Abflachung des Fußgewölbes und unauffällige Plantarfaszie. Normale Artikulation im Rückfuß, Mittelfußes und Vorfußes. Im Seitenvergleich rechts geringere degenerative Veränderungen des Großzehengrundgelenkes. Keine Signalauffälligkeiten an den Beuge- und Strecksehnen.

Impression

Note:

Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links.

Recommendations

Nil Known

Additional Resources Included in Document

Entry 2 - fullUrl = http://hl7.eu/fhir/imaging-r5/DiagnosticReport/DiagnosticReportSemiStructured

Resource DiagnosticReport:

Id: DiagnosticReportSemiStructured

Code:
( http://loinc.org: 24802-1 )

Identifier:
http://example.org/myhosptital/reportidentifiers: o32u4js8492ff

BasedOn: Identifier: Accession ID/123456789

Status: final

Category:
Radiologie ( http://terminology.hl7.org/CodeSystem/v2-0074: RAD )

( http://loinc.org: 85430-7 )

( http://hl7.eu/fhir/eu-health-data-api/CodeSystem/eehrxf-document-priority-category-cs: Medical-Imaging )

Subject: Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29

Period: 2025-05-08

Performer:
Radiology Zentrum Bremen

Results Interpreter:
Dr. Lucas Gasenzer(official): Radiologist at Radiology Zentrum Bremen

Studies:

ImagingStudy: extension = Lower extremity; identifier = Study Instance UID: DICOM Unique Id#urn:oid:1.2.276.2000010.784732; status = available; modality = Magnetic Resonance; started = 2025-04-29

ImagingStudy: extension = Lower extremity; identifier = Study Instance UID: DICOM Unique Id#urn:oid:1.2.276.2000010.784733; status = available; modality = Magnetic Resonance; started = 2025-04-29

Composition: Radiology Report for the left/right foot study

Results interpreter:

Observation Radiology Study observation (narrative)

Conclusion: Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links.

Presented form:

application/pdf @ http://hl7.eu/fhir/imaging-r5/Binary/BinarySemistructuredReport

Id:	DiagnosticReportSemiStructured
Code:	( http://loinc.org: 24802-1 )
Identifier:	http://example.org/myhosptital/reportidentifiers: o32u4js8492ff
BasedOn:	Identifier: Accession ID/123456789
Status:	final
Category:	Radiologie ( http://terminology.hl7.org/CodeSystem/v2-0074: RAD ) ( http://loinc.org: 85430-7 ) ( http://hl7.eu/fhir/eu-health-data-api/CodeSystem/eehrxf-document-priority-category-cs: Medical-Imaging )
Subject:	Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29
Period:	2025-05-08
Performer:	Radiology Zentrum Bremen
Results Interpreter:	Dr. Lucas Gasenzer(official): Radiologist at Radiology Zentrum Bremen
Studies:	ImagingStudy: extension = Lower extremity; identifier = Study Instance UID: DICOM Unique Id#urn:oid:1.2.276.2000010.784732; status = available; modality = Magnetic Resonance; started = 2025-04-29 ImagingStudy: extension = Lower extremity; identifier = Study Instance UID: DICOM Unique Id#urn:oid:1.2.276.2000010.784733; status = available; modality = Magnetic Resonance; started = 2025-04-29
Composition:	Radiology Report for the left/right foot study
Results interpreter:	Observation Radiology Study observation (narrative)
Conclusion:	Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links.
Presented form:	application/pdf @ http://hl7.eu/fhir/imaging-r5/Binary/BinarySemistructuredReport

Entry 3 - fullUrl = http://hl7.eu/fhir/imaging-r5/Patient/PatientSemiStructuredReport

Resource Patient:

Language: en
Profile: Patient (EU core)
Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29

Entry 4 - fullUrl = http://hl7.eu/fhir/imaging-r5/ImagingStudy/ImagingStudySemiStructuredReport1

Resource ImagingStudy:

Language: en
Profile: ImagingStudy: Reported Study
Extension: Anatomical Region: Lower extremity
identifier: Study Instance UID/urn:oid:1.2.276.2000010.784732
status: Available
modality: Magnetic Resonance
subject: Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29
started: 2025-04-29
basedOn: Identifier: Accession ID/123456789
series
Extension Definition for ImagingStudy.series.laterality for Version 5.0: Left lateral
uid: 1.2.276.2000010.784732.1
number: 1
modality: Magnetic Resonance
description: PD FatSat 3D (1.0mm) sagittal
BodySites
- Concept
* Entire left foot (body structure)
performer
function: custodian
actor: Radiology Zentrum Bremen
performer
function: location
actor: Radiology Zentrum Bremen

Entry 5 - fullUrl = http://hl7.eu/fhir/imaging-r5/ImagingStudy/ImagingStudySemiStructuredReport2

Resource ImagingStudy:

Language: en
Profile: ImagingStudy: Reported Study
Extension: Anatomical Region: Lower extremity
identifier: Study Instance UID/urn:oid:1.2.276.2000010.784733
status: Available
modality: Magnetic Resonance
subject: Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29
started: 2025-04-29
basedOn: Identifier: Accession ID/123456789
series
Extension Definition for ImagingStudy.series.laterality for Version 5.0: Left lateral
uid: 1.2.276.2000010.784733.1
number: 1
modality: Magnetic Resonance
description: PD FatSat 3D (1.0mm) sagittal
BodySites
- Concept
* Entire right foot (body structure)
performer
function: custodian
actor: Radiology Zentrum Bremen
performer
function: location
actor: Radiology Zentrum Bremen
series
Extension Definition for ImagingStudy.series.laterality for Version 5.0: Right lateral
uid: 1.2.276.2000010.784733.2
number: 2
modality: Magnetic Resonance
description: T1 (2.5mm) axial
BodySites
- Concept
* Entire right foot (body structure)
performer
function: custodian
actor: Radiology Zentrum Bremen
performer
function: location
actor: Radiology Zentrum Bremen

Entry 6 - fullUrl = http://hl7.eu/fhir/imaging-r5/PractitionerRole/PractitionerRoleSemiStructuredReportAuthor

Resource PractitionerRole:

Language: en
Profile: PractitionerRole (EU core)
Dr. Lucas Gasenzer(official): Radiologist at Radiology Zentrum Bremen
Practitioner: Dr. Lucas Gasenzer(official)
Organization: Radiology Zentrum Bremen
Role: Radiologist

Entry 7 - fullUrl = http://hl7.eu/fhir/imaging-r5/Practitioner/PractitionerSemiStructuredReportAuthor

Resource Practitioner:

Language: en
Profile: Practitioner (EU core)
Dr. Lucas Gasenzer(official)

Entry 8 - fullUrl = http://hl7.eu/fhir/imaging-r5/Organization/OrganizationSemiStructuredReport

Resource Organization:

Language: en
Profile: Organization (EU core)
Radiology Zentrum Bremen
Contact Detail
+49 421 1234567
Schwachhauser Heerstraße 54 Bremen 28209 Germany (work)

Entry 9 - fullUrl = http://hl7.eu/fhir/imaging-r5/Binary/BinarySemistructuredReport

Resource Binary:

Language: en
contentType: application/pdf
data: JVBERi0xLjQNCiWio4+TDQo5IDAgb2Jq... (base64 data - 263,952 base64 chars)

Entry 10 - fullUrl = http://hl7.eu/fhir/imaging-r5/Observation/ObservationNarrative

Resource Observation:

Language: en
Profile: Observation: Narrative Report
status: Final
code: Radiology Study observation (narrative)
subject: Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29
effective: 2025-05-08 00:00:00+0000
performer: Dr. Lucas Gasenzer(official): Radiologist at Radiology Zentrum Bremen
value: Linker Fuß: Allenfalls geringe Abflachung des Fußgewölbes und normale Dicke der Plantarfaszie. Regelrechte Artikulation im Rückfuß, Mittelfuß und Vorfußes. Im Großzehengrundgelenk deutliche Verschmälerung des Gelenkspaltes und Ausbildung von subchondralen Geröllzysten sowie deutliche postoperative Veränderungen nach Umstellungsosteotomie. Die Beuge- und Strecksehnen sind intakt. Rechter Fuß: Analog zur Gegenseite zeigt sich eine allenfalls geringe Abflachung des Fußgewölbes und unauffällige Plantarfaszie. Normale Artikulation im Rückfuß, Mittelfußes und Vorfußes. Im Seitenvergleich rechts geringere degenerative Veränderungen des Großzehengrundgelenkes. Keine Signalauffälligkeiten an den Beuge- und Strecksehnen.

Links: Table of Contents | QA Report

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