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

: DiagnosticReport: structured report

Raw xml | Download


<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="DiagnosticReportStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/DiagnosticReportEuImaging"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="extensions"/>
  </text>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>🔗 
      <reference value="Observation/WeightObservation"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>🔗 
      <reference value="Observation/HeightObservation"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>🔗 
      <reference value="Observation/BPObservation"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>🔗 
      <reference value="Observation/HRObservation"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/HL7IDRRecommendation">
    <valueReference>🔗 
      <reference value="ServiceRequest/ComeBackNextYearServiceRequest"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://example.org/myhosptital/reportidentifiers"/>
    <value value="dfkjewoieoijwoskdjf"/>
  </identifier>
  <basedOn>
    <type value="ServiceRequest"/>
    <identifier>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
          <code value="ACSN"/>
        </coding>
      </type>
      <system value="http://example.org/myhosptital/accessionsystem"/>
      <value value="87654321"/>
    </identifier>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="CUS"/>
      <display value="Cardiac Ultrasound"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://www.ama-assn.org/go/cpt"/>
      <code value="93351"/>
      <display
               value="Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en) or 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/PatientStructuredReport"/>
  </subject>
  <effectiveDateTime value="2003-06-01"/>
  <performer>🔗 
    <reference value="Organization/OrganizationStructuredReport"/>
  </performer>
  <resultsInterpreter>🔗 
    <reference
               value="PractitionerRole/PractitionerRoleStructuredReportAuthor"/>
  </resultsInterpreter>
  <result>🔗 
    <reference value="Observation/RestWmsi01"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi02"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi03"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi04"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi05"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi06"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi07"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi08"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi09"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi10"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi12"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi13"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi14"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi15"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi16"/>
  </result>
  <result>🔗 
    <reference value="Observation/RestWmsi17"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi01"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi02"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi03"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi04"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi05"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi06"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi07"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi08"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi09"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi10"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi12"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi13"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi14"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi15"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi16"/>
  </result>
  <result>🔗 
    <reference value="Observation/StressWmsi17"/>
  </result>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Stress Findings**
Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Right Ventricle**
The right ventricle is not well visualized. There is mild right ventricular hypertrophy."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Atria**
A patent foramen ovale is present and there is low risk for embolism. The left atrium is small."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="Mitral Valve
The mitral valve leaflets appear normal. There is no evidence of stenosis, fluttering, or prolapse. Mitral valve prolapse cannot be excluded. No significant mitral valve stenosis. The mitral regurgitant jet is posteriorly directed, which is consistent with anterior leaflet pathology. There is a porcine mitral valve."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Tricuspid Valve**
The tricuspid valve leaflets are thickened and/or calcified, but open well. There is a ruptured tricuspid valve chordae with a flail free wall leaflet. No significant tricuspid stenosis. There is mild to moderate tricuspid regurgitation. The prosthetic tricuspid valve is not well visualized."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Aortic Valve**
The aortic valve is trileaflet. The aortic valve is normal in structure and function. Cannot exclude aortic valvular vegetation. Hemodynamically significant valvular aortic stenosis cannot be excluded. No aortic regurgitation is present. The prosthetic aortic valve is not well visualized."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Pulmonic Valve**
The pulmonic valve is normal in structure and function. A pulmonic valvular vegetation cannot be excluded. Infundibular pulmonic stenosis is noted. There is no pulmonic valvular regurgitation. The prosthetic pulmonic valve is well‐seated."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Vessels**
The aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size."/>
  </note>
  <note>
    <extension url="http://hl7.org/fhir/StructureDefinition/annotationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://loinc.org"/>
          <code value="59776-5"/>
          <display value="Procedure findings Narrative"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text
          value="**Pericardium**
There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion."/>
  </note>
  <study>🔗 
    <reference value="ImagingStudy/ImagingStudStructuredReport"/>
  </study>
  <media>
    <comment value="Rest"/>
    <link>🔗 
      <reference value="DocumentReference/StructuredKeyImageRest"/>
    </link>
  </media>
  <media>
    <comment value="Stress"/>
    <link>🔗 
      <reference value="DocumentReference/StructuredKeyImageStress"/>
    </link>
  </media>
  <composition>🔗 
    <reference value="Composition/CompositionStructured"/>
  </composition>
  <conclusion
              value="This was a normal stress echocardiogram.
Nothing wrong with this patient
See you next year."/>
  <presentedForm>
    <contentType value="application/pdf"/>
    <language value="de-DE"/>
    <url value="./Binary/structured-pdf"/>
    <pages value="3"/>
  </presentedForm>
</DiagnosticReport>