HL7 Europe Imaging Report R5
0.1.1-build - 150

HL7 Europe Imaging Report R5, 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-r5/ and changes regularly. See the Directory of published versions

: Composition: semi-structured

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<Composition xmlns="http://hl7.org/fhir">
  <id value="CompositionSemiStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/CompositionEuImaging"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="extensions"/>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/event-basedOn">
    <valueReference>
      <type value="ServiceRequest"/>
      <identifier>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/v3-ActClass#v2-0203"/>
            <code value="ACSN"/>
          </coding>
        </type>
        <system value="http://example.org/myhosptital/accessionsystem"/>
        <value value="123456789"/>
      </identifier>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/DiagnosticReportEuImagingReferenceExtensionEuImaging">
    <valueReference>🔗 
      <reference value="DiagnosticReport/DiagnosticReportSemiStructured"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://example.org/myhosptital/reportidentifiers"/>
    <value value="o32u4js8492ff"/>
  </identifier>
  <version value="1.0.0"/>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="24802-1"/>
      <display value="MR Knee"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="RAD"/>
      <display value="Radiology"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/PatientSemiStructuredReport"/>
  </subject>
  <date value="2025-05-08"/>
  <author>🔗 
    <reference
               value="PractitionerRole/PractitionerRoleSemiStructuredReportAuthor"/>
  </author>
  <author>🔗 
    <reference value="Organization/OrganizationSemiStructuredReport"/>
  </author>
  <title value="Radiology Report for the left/right foot study"/>
  <section>
    <title value="Imaging Study"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18726-0"/>
      </coding>
    </code>
    <text>
      <extension url="http://hl7.org/fhir/StructureDefinition/textLink">
        <extension url="htmlid">
          <valueString value="study1"/>
        </extension>
        <extension url="data">
          <valueUri value="#study1-ref"/>
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/textLink">
        <extension url="htmlid">
          <valueString value="study2"/>
        </extension>
        <extension url="data">
          <valueUri value="#study2-ref"/>
        </extension>
      </extension>
      <status value="generated"/>
    </text>
    <entry id="study1-ref">🔗 
      <reference value="ImagingStudy/ImagingStudySemiStructuredReport1"/>
    </entry>
    <entry id="study2-ref">🔗 
      <reference value="ImagingStudy/ImagingStudySemiStructuredReport2"/>
    </entry>
  </section>
  <section>
    <title value="Order"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55115-0"/>
        <display value="Requested imaging studies information Document"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11329-0"/>
        <display value="History general Narrative - Reported"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="Procedure"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55111-9"/>
        <display value="Current imaging procedure descriptions Document"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="unavailable"/>
        <display value="Unavailable"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="Comparison"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18834-2"/>
        <display value="Radiology Comparison study (narrative)"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation id="finding-note1">
        <text
              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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation id="finding-note2">
        <text
              value="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."/>
      </valueAnnotation>
    </extension>
    <title value="Findings"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59776-5"/>
        <display value="Procedure findings Narrative"/>
      </coding>
    </code>
    <text>
      <extension url="http://hl7.org/fhir/StructureDefinition/textLink">
        <extension url="htmlid">
          <valueString value="note1"/>
        </extension>
        <extension url="data">
          <valueUri value="#finding-note1"/>
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/textLink">
        <extension url="htmlid">
          <valueString value="note2"/>
        </extension>
        <extension url="data">
          <valueUri value="#finding-note2"/>
        </extension>
      </extension>
      <status value="generated"/>
    </text>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation id="impression-note">
        <text
              value="Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links."/>
      </valueAnnotation>
    </extension>
    <title value="Impression"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="19005-8"/>
        <display value="Radiology Imaging study [Impression] (narrative)"/>
      </coding>
    </code>
    <text>
      <extension url="http://hl7.org/fhir/StructureDefinition/textLink">
        <extension url="htmlid">
          <valueString value="note"/>
        </extension>
        <extension url="data">
          <valueUri value="#impression-note"/>
        </extension>
      </extension>
      <status value="generated"/>
    </text>
  </section>
  <section>
    <title value="Recommendations"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18783-1"/>
        <display value="Radiology Study recommendation (narrative)"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
</Composition>