HL7 Europe Imaging Study Report
0.1.1-build - ci-build 150

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

Example Composition: Composition for stress test ultrasound

Title: Transthoracic echocardiogram

Id: CompositionStructured
Version: 1
Identifier:

http://example.org/myhosptital/reportidentifiers: dfkjewoieoijwoskdjf

Status: final
Type:

transthoracic echocardiogram ( http://www.ama-assn.org/go/cpt: 93351 )

Category:

Cardiac Ultrasoundy ( http://terminology.hl7.org/CodeSystem/v2-0074: CUS )

Subject: 3D TEE 2D(official) (no stated gender), DoB: 1976-04-29 ( 00 CARDIAC 2)
Date: 2025-09-05 02:22:00+0000
Author:

PractitionerRole Cardiology

Organization Ultrasound centrum

Imaging Study

Code:

Radiology studies (set) ( http://loinc.org: 18726-0 )

References:

Order

Code:

Requested imaging studies information Document ( http://loinc.org: 55115-0 )

References:

  • Identifier: Accession ID/87654321

History

Code:

History general Narrative - Reported ( http://loinc.org: 11329-0 )

References:

Procedure

Code:

Current imaging procedure descriptions Document ( http://loinc.org: 55111-9 )

Reason for absence of content:

Unavailable ( unavailable )

Comparison

Code:

Radiology Comparison study (narrative) ( http://loinc.org: 18834-2 )

Reason for absence of content:

Nil Known ( nilknown )

Findings

Code:

Findings ( http://loinc.org: 59776-5 )

Stress Findings Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress.

Right Ventricle The right ventricle is not well visualized. There is mild right ventricular hypertrophy.

Atria A patent foramen ovale is present and there is low risk for embolism. The left atrium is small.

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.

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.

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.

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.

Vessels The aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size.

Pericardium There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion.

References:

Impression

Code:

Radiology Imaging study [Impression] (narrative) ( http://loinc.org: 19005-8 )

This was a normal stress echocardiogram. Nothing wrong with this patient See you next year.

Recommendations

Code:

Radiology Study recommendation (narrative) ( http://loinc.org: 18783-1 )

References: