Profile: ImComposition Parent: CompositionEu Title: "Imaging Composition" Description: "Clinical document used to represent a Imaging Study Report for the scope of the HL7 Europe project." * . ^short = "Imaging Report composition" * . ^definition = """ Imaging Study Report composition.\n A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement.\n While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.\n \n The `text` field of each section SHALL contain a textual representation of all listed entries. """ * insert SetFmmAndStatusRule( 1, draft ) * identifier 1..* * extension contains ImDiagnosticReportReference named diagnosticreport-reference 1..1 * extension[diagnosticreport-reference].valueReference only Reference ( ImDiagnosticReport ) * custodian only Reference( $EuOrganization ) * ^short = "Organization that manages the Imaging Report" * attester 0..* * insert SliceElement( #value, mode ) * attester contains legalAuthenticator 0..* and resultValidator 0..* * attester[legalAuthenticator] * mode 1..1 * mode = http://hl7.org/fhir/composition-attestation-mode#legal * party only Reference( $EuPractitionerRole ) * time 1..1 * attester[resultValidator] * mode 1..1 * mode = http://hl7.org/fhir/composition-attestation-mode#professional * party only Reference( $EuPractitionerRole ) * time 1..1 * author 1..* * insert SliceElement( #profile, $this ) * author contains author 0..* and authoringDevice 0..* * author[author] only Reference( $EuPractitionerRole ) * author[authoringDevice] only Reference( $EuDevice ) // type of the report. Matching DiagnosticReport.code // code * type from ImImagingReportTypesEuVS (extensible) // purposefull versionless * type * coding 1..* * insert SliceElement( #value, $this ) * coding contains eu-template 1..1 * coding[eu-template] = Hl7EuDocumentTypes#imaging-report-v0-0-1 "Imaging Report V0.0.1" * category 1..* * insert SliceElement( #value, $this ) * category contains imaging 1..1 * category[imaging] = $loinc#18748-4 "Diagnostic imaging study" * category[imaging].coding 1..1 * status * event 2..* * insert SliceElement( #value, detail.concept ) * event contains imagingstudy 1..* and procedure 1..* * event[imagingstudy] * ^short = "Modality" * ^definition = "The type of imaging modality used to perform the study." * detail 1..* * detail from https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (extensible) * detail only CodeableReference ( ImImagingStudy ) * event[procedure] * ^short = "Study Type" * ^definition = "The type of imaging study performed." * detail 1..* * detail from https://www.hl7.org/fhir/valueset-procedure-reason.html (extensible) * detail only CodeableReference ( ImProcedure ) * section.code 1..1 * section * insert SliceElement( #value, code ) * section.emptyReason from ImSectionEmptyReason (preferred) * section obeys eu-imaging-composition-1 * section contains imagingstudy 1..1 and order 1..1 and history 1..1 and procedure 1..1 and comparison 1..1 and findings 1..1 and impression 1..1 and recommendation 1..1 and communication 0..1 // ///////////////////////////////// IMAGING STUDY SECTION /////////////////////////////////////// * section[imagingstudy] * ^short = "Imaging Study" * ^definition = "This section holds information related to the imaging studies covered by this report." // * title = "Imaging Studies" * code = $loinc#18726-0 * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains imagingstudy 1..* * entry[imagingstudy] * ^short = "Imaging Study Reference" * ^definition = "This entry holds a reference to the Imaging Study instance that is associated with this Composition." * entry[imagingstudy] only Reference(ImImagingStudy) // ///////////////////////////////// ORDER SECTION /////////////////////////////////////// * section[order] * ^short = "Order" * ^definition = "This section holds information related to the order for the imaging study." * code = $loinc#55115-0 "Requested imaging studies information Document" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains order 0..* * entry[order] * ^short = "Order reference" * ^definition = "This entry holds a reference to the order for the Imaging Study and report." * entry[order] only Reference(ImOrder) // // ///////////////////////////////// HISTORY SECTION /////////////////////////////////////// * section[history] * ^short = "History" * code = $loinc#11329-0 "History general Narrative - Reported" * extension contains $note-url named note 0..* // // ///////////////////////////////// PROCEDURE SECTION /////////////////////////////////////// * section[procedure] * ^short = "Procedure" * code = $loinc#55111-9 "Current imaging procedure descriptions Document" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains procedure 0..* * entry[procedure] only Reference(ImProcedure) // ////////////////// COMPARISON SECTION ////////////////////////// * section[comparison] * ^short = "History" * code = $loinc#18834-2 "Radiology Comparison study (narrative)" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains comparedstudy 0..* * entry[comparedstudy] only Reference( ImImagingStudy or ImImagingSelection ) // /////////////////// FINDINGS SECTION ////////////////////////// * section[findings] * ^short = "Findings" * code = $loinc#59776-5 "Findings" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains finding 0..* and keyimage 0..* * entry[finding] only Reference(ImFinding) * entry[keyimage] only Reference(ImKeyImageDocumentReference or ImKeyImageImagingSelection) // /////////////////// IMPRESSION SECTION ////////////////////////// * section[impression] * ^short = "Impressions" * code = $loinc#19005-8 "Radiology Imaging study [Impression] (narrative)" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains finding 0..* and impression 0..* and keyimage 0..* * entry[finding] only Reference(ImFinding) * entry[impression] only Reference( $EuCondition ) * entry[keyimage] only Reference(ImKeyImageDocumentReference or ImKeyImageImagingSelection) // /////////////////// RECOMMENDATION SECTION ////////////////////////// * section[recommendation] * ^short = "Recommendations" * code = $loinc#18783-1 "Radiology Study recommendation (narrative)" * extension contains $note-url named note 0..* * entry * insert SliceElement( #profile, $this ) * entry contains careplan 0..* * entry[careplan] only Reference($EuCarePlan) // /////////////////// COMMUNICATION SECTION ////////////////////////// * section[communication] * ^short = "Communications" // a proper code is needed * code = $loinc#18783-1 "Radiology Study recommendation (narrative)" * extension contains $note-url named note 0..* Invariant: eu-imaging-composition-1 Description: "When a section is empty, the emptyReason extension SHALL be present." Severity: #error Expression: "entry.empty() and emptyReason.exists()" Extension: ImDiagnosticReportReference Id: im-composition-diagnosticReportReference Title: "Document DiagnosticReport Reference" Description: """ This extension provides a reference to the DiagnosticReport instance that is associated with this Composition. """ Context: Composition // publisher, contact, and other metadata here using caret (^) syntax (omitted) * insert ExtensionContext(Composition) * insert SetFmmAndStatusRule ( 2, draft ) * value[x] only Reference (ImDiagnosticReport)