Medical Imaging Report

A.1 Report header data elements (eHN)

Identification of the patient/subject

Patient/subject related contact information

Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.

Intended recipient or recipients of the report, e.g., GP, another specialist. Multiple recipients could be provided.

Author (by whom the imaging report or a subset of its results was authored). Multiple authors could be provided.

The person taking responsibility for the medical content of the document.

Result validator

Document metadata

Note: an imaging report could respond to multiple orders.

Note: an imaging report could respond to multiple reasons.

Note: a specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes.

Examination Report

Note: this part records the technical details of the performed procedures and may include information about protocol, imaging phases, imaging device, anatomical location, performer, place, date and time of performance.

Medication section includes information about medication administered during the medical imaging examination (contrast, sedation, stress agents), etc.

Adverse reactions manifested during imaging investigation.

Note: The results summarise the findings and observations by the health professional following the imaging study. Note: this part includes textual as well as structured results or findings of the imaging investigation.

A concise and clinically contextualised summary including interpretation/impression of the diagnostic report

Recommendation

Key images associated with this report

Comparison study

Presented form

The data set defines the contents of the key information about the imaging study as conveyed by the imaging study manifest data set. The imaging study manifest contains key information about the imaging study that is referenced, including the “pointers” that allow access to the series of images. It is important to note that the metadata used in expressing the filters associated with the querying for a list of imaging studies and/or imaging reports are defined in Section 2 Article 10: Selection List and filtering Parameters. These parameters are expressed as coded values from standardised value sets to ensure a robust search for a list of relevant imaging studies. Such metadata filtering parameters are associated with imaging studies, but may not be present in the content of the imaging study manifest.

Clinical document used to represent a Imaging Study Report for the scope of the HL7 Europe project.

Diagnostic Report profile for Imaging Reports. This document represents the report of an imaging study. It is the anchor resource that refers to all structured data as well as the Composition resource that contains the narrative text of the report.

This profile represents an imaging study instance.

Producer profile for this IG

Adverse event during imaging procedure.

This profile represents a suspected allergic reaction occurred during or due to an imaging study procedure.

Clinical document used to represent a Imaging Study Report for the scope of the HL7 Europe project.

Health Insurance and Payment Information. This resource represents the insurance coverage for a patient.

Finding during imaging procedure.

Health Insurance Provider profile for healthcare organizations, this resource contains all information related to a health insurance provider.

This profile represents the device used to author the Imaging Diagnostic Report.

This profile on Device represents the imaging device.

A document containing key images for a patient. It can refer to a DICOM or non-DICOM image. When referring to a DICOM image, the DocumentReference.content.attachment.url should be a WADO-URI. When referring to a non-DICOM image, the DocumentReference.content.attachment.url should be a direct URL to the image.

When the resource represents a DICOM instance it SHALL contain a the SOP Instance UID in the identifier element. When the resource represents a DICOM series it SHALL contain the Series Instance UID in the identifier element.

This profile on ServiceRequest represents the order for the Imaging Study and report.

Human patient representing the subject of a medical imaging study for the scope of the HL7 Europe project.

This profile on Procedure represents the imaging procedure.

Represents the part of an imaging study that relates to a procedure phase such as e.g., without contrast, arterial phase, venous phase, delayed phase. Only some types of studies have phases.

The healtcare professional who performed the study/procedure.

Impression of the imaging study. A conclusion drawn by the author based on the findings of the study.

Information recipient (intended recipient or recipients of the report, e.g., GP, another specialist).

Legal authenticator (The person taking responsibility for the medical content of the document).

Based on EPD Medication profile. Reference it once it is published.

Record of medication administration during imaging procedure.

The healthcare professional who placed the order for the study.

Organization profile for healthcare organizations, this resource contains all information related to healthcare organizations.

Practitioner profile for healthcare professionals, this resource contains all demographic information releted to healthcare professionals.

Practitioner Role profile for healthcare professionals, all references to healthcare professionals will be of this type.

A record for the radiation dose the subject has been exposed to during an imaging procedure.

This resource is a placeholder pending further refinement in this topic.

E.g. based on information from https://dicom.nema.org/medical/dicom/current/output/html/part16.html.

Recommended care plan for the patient based on the imaging study. Contains the narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that the care plan could be provided in a structured and coded format.

Author (by whom the imaging report or a subset of its results was authored). Multiple authors could be provided.

Result validator. The healthcare professional who is responsible validating the diagnostic report.

This profile defines a placeholder for an Endpoint for a viewer that can be used to access the study, serie it is present on. The application is based on IHE-IID.

This profile defines the WADO endpoint for accessing imaging study content.

This profile on Identifier represents the Accession Number for the Imaging Order.

This profile on Reference represents a reference to an Imaging Order.

This extension provides a reference to the DiagnosticReport instance that is associated with this Composition.

Replicates AllergyIntolerance.criticality to introduce functionality in AdverseEvent resource.

Codes to be used in DiagnosticReport.supportInfo for imaging reports.

Imaging Report Types. This version includes only one code as suggested by the eHN guideline. To add specificity the https://loinc.org/kb/users-guide/loinc-rsna-radiology-playbook-user-guide/ could be incorporated as the source of imaging study/report types.

Units for Radiation Dose Observations.

This code system defines various codes used to define ValueSets for Endpoints within the HL7-EU imaging IG.

Code system for codes to be used in DiagnosticReport.supportInfo for imaging reports.

Code system for codes that are defined in DICOM but for which no matching code system is available in FHIR.

This concept map defines the mapping between the A.1.1 Identification of the patient/subject section and the FHIR profiles.

This concept map defines the mapping between the A.1.2 Patient/subject related contact information section and the FHIR profiles.

This concept map defines the mapping between the A.1.3. Health Insurance and Payment Information section and the FHIR profiles.

This concept map defines the mapping between the A.1.4 Information Recipient section and the FHIR profiles.

This concept map defines the mapping between the A.1.5 Information Author section and the FHIR profiles.

This concept map defines the mapping between the A.1.6 Legal Authenticator section and the FHIR profiles.

This concept map defines the mapping between the A.1.7 Result Validator section and the FHIR profiles.

This concept map defines the mapping between the A.1.8 Document Metadata section and the FHIR profiles.

This concept map defines the mapping between the A.2 Order Information section and the FHIR profiles.

This concept map defines the mapping between the A.3 Order Reason section and the FHIR profiles.

This concept map defines the mapping between the A.3 Order Reason section and the FHIR profiles.

The Specimen relates to a different type of information stored in a PACS: digital pathology. This has to analysed in more detail before inclusion in the IG. One of the things that might be impacted is the structure of the report.

The procedure information is expected to be part of the ImProcedure profile and not on ImagingStudy.procedure as there is a large overlap in information that is to be presented.

Maps on A.5.2-ImagingProcedureMedication section of the eHN Medical Imaging Report to the FHIR profiles.

Maps on A.5.2-ImagingProcedureMedication section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.5.4 Results section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.5.5 Results section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.5.6 Results section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.6 Key Images section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.7 Key Images section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the A.8 Presented Form section of the eHN Medical Imaging Report to the FHIR profiles.

Maps the B Imaging study manifest data set section of the eHN Medical Imaging Report to the FHIR profiles.