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

: Composition for stress test ultrasound - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="CompositionStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImComposition"/>
  </meta>
  <language value="en-GB"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-GB" lang="en-GB"><p class="res-header-id"><b>Generated Narrative: Composition CompositionStructured</b></p><a name="CompositionStructured"> </a><a name="hcCompositionStructured"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Language: en-GB</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ImComposition.html">Composition: Imaging Report</a></p></div><p><b>Based on</b>: Identifier: Accession ID/87654321</p><p><b>Document DiagnosticReport Reference</b>: <a href="DiagnosticReport-DiagnosticReportStructured.html">Diagnostic Report for 'transthoracic echocardiogram' for '-&gt;3D TEE 2D(official) (no stated gender), DoB: 1976-04-29 ( 00 CARDIAC 2)'</a></p><p><b>identifier</b>: <code>http://example.org/myhosptital/reportidentifiers</code>/dfkjewoieoijwoskdjf</p><p><b>version</b>: 1</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 93351}">transthoracic echocardiogram</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 CUS}">Cardiac Ultrasoundy</span></p><p><b>date</b>: 2025-09-05 02:22:00+0000</p><p><b>author</b>: </p><ul><li><a href="PractitionerRole-PractitionerRoleStructuredReportAuthor.html">PractitionerRole Cardiology</a></li><li><a href="Organization-OrganizationStructuredReport.html">Organization Ultrasound centrum</a></li></ul><p><b>title</b>: Transthoracic echocardiogram</p></div>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/event-basedOn">
    <valueReference>
      <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>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/im-composition-diagnosticReportReference">
    <valueReference>🔗 
      <reference value="DiagnosticReport/DiagnosticReportStructured"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://example.org/myhosptital/reportidentifiers"/>
    <value value="dfkjewoieoijwoskdjf"/>
  </identifier>
  <version value="1"/>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://www.ama-assn.org/go/cpt"/>
      <code value="93351"/>
      <display value="transthoracic echocardiogram"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="CUS"/>
      <display value="Cardiac Ultrasoundy"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/PatientStructuredReport"/>
  </subject>
  <date value="2025-09-05T02:22:00.000Z"/>
  <author>🔗 
    <reference
               value="PractitionerRole/PractitionerRoleStructuredReportAuthor"/>
  </author>
  <author>🔗 
    <reference value="Organization/OrganizationStructuredReport"/>
  </author>
  <title value="Transthoracic echocardiogram"/>
  <section>
    <title value="Imaging Study"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18726-0"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="ImagingStudy/ImagingStudStructuredReport"/>
    </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>
  </section>
  <section>
    <title value="History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11329-0"/>
        <display value="History general Narrative - Reported"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/WeightObservation"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/HeightObservation"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/BPObservation"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/HRObservation"/>
    </entry>
  </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>
    <emptyReason>
      <coding>
        <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>
    <emptyReason>
      <coding>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="**Stress Findings**
Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="**Right Ventricle**
The right ventricle is not well visualized. There is mild right ventricular hypertrophy."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="**Atria**
A patent foramen ovale is present and there is low risk for embolism. The left atrium is small."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <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."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="**Pericardium**
There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion."/>
      </valueAnnotation>
    </extension>
    <title value="Findings"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59776-5"/>
        <display value="Findings"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/RestWmsi01"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi02"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi03"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi04"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi05"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi06"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi07"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi08"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi09"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi10"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi12"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi13"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi14"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi15"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi16"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/RestWmsi17"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi01"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi02"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi03"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi04"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi05"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi06"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi07"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi08"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi09"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi10"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi12"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi13"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi14"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi15"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi16"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/StressWmsi17"/>
    </entry>
    <entry>🔗 
      <reference value="DocumentReference/StructuredKeyImageStress"/>
    </entry>
    <entry>🔗 
      <reference value="DocumentReference/StructuredKeyImageRest"/>
    </entry>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="This was a normal stress echocardiogram.
Nothing wrong with this patient
See you next year."/>
      </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>
  </section>
  <section>
    <title value="Recommendations"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18783-1"/>
        <display value="Radiology Study recommendation (narrative)"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="ServiceRequest/ComeBackNextYearServiceRequest"/>
    </entry>
  </section>
</Composition>