ImagingReport-knee-mri-example
type: Bundle
node role: treeRoot
id:
  v: ImagingReport-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImReport
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImReport
type:
  v: document
timestamp:
  v: 1993-11-29T12:36:56+00:00
entry:
  full url:
    v: Composition/1
  resource: 1
entry:
  full url:
    v: ImagingStudy/1
  resource: 1
entry:
  full url:
    v: Patient/1
  resource: 1
entry:
  full url:
    v: Practitioner/1
  resource: 1
entry:
  full url:
    v: Organization/1
  resource: 1
entry:
  full url:
    v: ServiceRequest/1
  resource: 1
entry:
  full url:
    v: Procedure/1
  resource: 1
entry:
  full url:
    v: Impression/1
  resource: 1
entry:
  full url:
    v: Finding/1
  resource: 1
entry:
  full url:
    v: DiagnosticReport/1
  resource: 1

1
type: Composition
id:
  v: Composition-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImComposition
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImComposition
language:
  v: en
text:
  status:
    v: extensions
  div: Generated Narrative: Composition Composition-knee-mri-example Language: en Profile: Composition: Imaging Report Document DiagnosticReport Reference: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 identifier: http://citymedial-imagecenter.org//123456 status: Final type: Imaging Report V0.0.1 category: Diagnostic imaging study date: 2021-01-01 00:00:00+0000 author: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 title: MRI LEFT KNEE custodian: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 event Details - Reference * Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 event Details - Reference * Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
extension:
  url:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/im-composition-diagnosticReportReference
  value: Reference
    link: http://hl7.eu/fhir/imaging-r5/DiagnosticReport/1
    reference:
      v: DiagnosticReport/1
identifier:
  system:
    v: http://citymedial-imagecenter.org/
  value:
    v: 123456
status:
  v: final
type:
  coding:
    system:
      v: http://hl7.eu/fhir/imaging-r5/CodeSystem/Hl7EuDocumentTypes
    code:
      v: imaging-report-v0-0-1
category:
  coding: https://loinc.org/rdf/18748-4
    system:
      v: http://loinc.org
    code:
      v: 18748-4
    display:
      v: Diagnostic imaging study
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1
date:
  v: 2021-01-01T00:00:00Z
author:
  link: http://hl7.eu/fhir/imaging-r5/Practitioner/1
  reference:
    v: Practitioner/1
title:
  v: MRI LEFT KNEE
custodian:
  link: http://hl7.eu/fhir/imaging-r5/Organization/1
  reference:
    v: Organization/1
event:
  detail:
    reference:
      link: http://hl7.eu/fhir/imaging-r5/ImagingStudy/1
      reference:
        v: ImagingStudy/1
event:
  detail:
    reference:
      link: http://hl7.eu/fhir/imaging-r5/Procedure/1
      reference:
        v: Procedure/1
section:
  title:
    v: Technique
  code:
    coding: https://loinc.org/rdf/18726-0
      system:
        v: http://loinc.org
      code:
        v: 18726-0
  text:
    status:
      v: generated
    div: Axial PD fat sat, coronal T1, coronal PD fat sat, coronal T2 fat sat, sagittal PD, and sagittal PD fat sat images were performed
  entry:
    link: http://hl7.eu/fhir/imaging-r5/ImagingStudy/1
    reference:
      v: ImagingStudy/1
section:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/note
    value: Annotation
      text:
        v: Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear
  title:
    v: Clinical information
  code:
    coding: https://loinc.org/rdf/55115-0
      system:
        v: http://loinc.org
      code:
        v: 55115-0
      display:
        v: Requested imaging studies information Document
  text:
    status:
      v: generated
    div: Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear.
  entry:
    link: http://hl7.eu/fhir/imaging-r5/ServiceRequest/1
    reference:
      v: ServiceRequest/1
section:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/note
    value: Annotation
      text:
        v: Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear
  title:
    v: History
  code:
    coding: https://loinc.org/rdf/11329-0
      system:
        v: http://loinc.org
      code:
        v: 11329-0
      display:
        v: History
  text:
    status:
      v: generated
    div: Injured playing football 3 weeks ago.
  entry:
    link: http://hl7.eu/fhir/imaging-r5/Impression/1
    reference:
      v: Impression/1
section:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/note
    value: Annotation
      text:
        v: None utilized.
  title:
    v: Contrast
  code:
    coding: https://loinc.org/rdf/55111-9
      system:
        v: http://loinc.org
      code:
        v: 55111-9
      display:
        v: Procedure
  text:
    status:
      v: generated
    div: None utilized.
  entry:
    link: http://hl7.eu/fhir/imaging-r5/Procedure/1
    reference:
      v: Procedure/1
section:
  title:
    v: Comparison
  code:
    coding: https://loinc.org/rdf/18834-2
      system:
        v: http://loinc.org
      code:
        v: 18834-2
      display:
        v: Comparison
  text:
    status:
      v: generated
    div: None available
  empty reason:
    coding: LA4720-4
      system:
        v: http://loinc.org
      code:
        v: LA4720-4
      display:
        v: None available
section:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/note
    value: Annotation
      text:
        v: FLUID: Moderate effusion. MENISCI: Medial: No evidence of a tear. Lateral: Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. CRUCIATE LIGAMENTS: Complete tear of the ACL, which is torn in the mid substance. The posterior cruciate ligament is intact. COLLATERAL LIGAMENTS: Grade 1 to grade 2 MCL sprain. There is edema in the deep fibers, as well as some in the in the superficial fibers and in the adjacent soft tissues. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. The lateral collateral ligament complex is intact. Edema is noted in the popliteus muscle belly and muscle-tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. EXTENSOR MECHANISM: Intact. CARTILAGE: Patellofemoral compartment: No chondral defect or area of high-grade chondral loss. Medial tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. Lateral tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. BONE MARROW: Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.
  title:
    v: Findings
  code:
    coding: https://loinc.org/rdf/59776-5
      system:
        v: http://loinc.org
      code:
        v: 59776-5
      display:
        v: Findings

1
type: ImagingStudy
id:
  v: 1
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImImagingStudy
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImImagingStudy
text:
  status:
    v: generated
  div: Generated Narrative: ImagingStudy 1 Profile: ImagingStudy: General identifier: Study Instance UID/999.999.3859744 status: Available modality: Magnetic Resonance subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 started: 2011-01-01 referrer: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 series uid: 999.999.94827453 modality: Magnetic Resonance description: Axial PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.9 unknown 1.2.840.10008.5.1.4.1.1.6.1: 1.2.840.10008.5.1.4.1.1.6.1 8 series uid: 999.999.94827454 modality: Magnetic Resonance description: Coronal T1 Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.21 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 20 series uid: 999.999.94827455 modality: Magnetic Resonance description: Coronal PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.7 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 6 series uid: 999.999.94827456 modality: Magnetic Resonance description: Coronal T2 fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.11 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 10 series uid: 999.999.94827457 modality: Magnetic Resonance description: Sagital PD Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.15 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 14 series uid: 999.999.94827458 modality: Magnetic Resonance description: Sagital PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.17 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 16
identifier:
  type:
    coding:
      system:
        v: http://hl7.eu/fhir/imaging-r5/CodeSystem/codesystem-missing-dicom-terminology
      code:
        v: 0020000D
      display:
        v: Study Instance UID
  system:
    v: urn:dicom:uid
  value:
    v: 999.999.3859744
status:
  v: available
modality:
  coding:
    system:
      v: http://dicom.nema.org/resources/ontology/DCM
    code:
      v: MR
    display:
      v: Magnetic Resonance
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1
started:
  v: 2011-01-01
referrer:
  link: http://hl7.eu/fhir/imaging-r5/Practitioner/1
  reference:
    v: Practitioner/1
series:
  uid:
    v: 999.999.94827453
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Axial PD fat sat
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.9
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.6.1
    number:
      v: 8
series:
  uid:
    v: 999.999.94827454
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Coronal T1
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.21
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.3.1
    number:
      v: 20
series:
  uid:
    v: 999.999.94827455
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Coronal PD fat sat
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.7
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.3.1
    number:
      v: 6
series:
  uid:
    v: 999.999.94827456
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Coronal T2 fat sat
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.11
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.3.1
    number:
      v: 10
series:
  uid:
    v: 999.999.94827457
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Sagital PD
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.15
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.3.1
    number:
      v: 14
series:
  uid:
    v: 999.999.94827458
  modality:
    coding:
      system:
        v: http://dicom.nema.org/resources/ontology/DCM
      code:
        v: MR
      display:
        v: Magnetic Resonance
  description:
    v: Sagital PD fat sat
  instance:
    uid:
      v: 999.999.133.1996.1.1800.1.6.17
    sop class:
      system:
        v: urn:ietf:rfc:3986
      code:
        v: 1.2.840.10008.5.1.4.1.1.3.1
    number:
      v: 16

1
type: Patient
id:
  v: Patient-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImPatient
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImPatient
text:
  status:
    v: generated
  div: Generated Narrative: Patient Patient-knee-mri-example Profile: Patient: Imaging John Smith Male, DoB: 1995-05-05 ( Medical Record number: 12345 (use: usual, ))
identifier:
  use:
    v: usual
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
      code:
        v: MR
      display:
        v: Medical Record number
  system:
    v: http://citymedial-imagecenter.org/
  value:
    v: 12345
name:
  use:
    v: usual
  text:
    v: John Smith
  family:
    v: Smith
  given:
    v: John
gender:
  v: male
birth date:
  v: 1995-05-05

1
type: Practitioner
id:
  v: referrer
meta:
  profile:
    v: http://hl7.eu/fhir/base-r5/StructureDefinition/practitioner-eu
    link: http://hl7.eu/fhir/base-r5/StructureDefinition/practitioner-eu
text:
  status:
    v: generated
  div: Generated Narrative: Practitioner referrer Profile: Practitioner (EU base) name: NationalRadMusculoskeletal
name:
  family:
    v: NationalRadMusculoskeletal

1
type: Organization
id:
  v: Organization-knee-mri-example
text:
  status:
    v: generated
  div: Generated Narrative: Organization Organization-knee-mri-example name: City Medical Imaging Center
name:
  v: City Medical Imaging Center

1
type: ServiceRequest
id:
  v: ServiceRequest-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImOrder
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImOrder
text:
  status:
    v: generated
  div: Generated Narrative: ServiceRequest ServiceRequest-knee-mri-example Profile: ServiceRequest: Imaging Order status: Draft intent: Order category: Imaging (procedure) subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
status:
  v: draft
intent:
  v: order
category:
  coding: http://snomed.info/id/363679005
    system:
      v: http://snomed.info/sct
    code:
      v: 363679005
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1

1
type: Procedure
id:
  v: ImProcedure-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImProcedure
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImProcedure
text:
  status:
    v: generated
  div: Generated Narrative: Procedure ImProcedure-knee-mri-example Profile: Procedure: Imaging Acquisition status: Completed code: MRI of the knee subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
status:
  v: completed
code:
  coding: http://snomed.info/id/123456
    system:
      v: http://snomed.info/sct
    code:
      v: 123456
    display:
      v: MRI of the knee
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1

1
type: Condition
id:
  v: ImImpression-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ConditionEu
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ConditionEu
text:
  status:
    v: generated
  div: Generated Narrative: Condition ImImpression-knee-mri-example Profile: Condition: EU Condition clinicalStatus: active subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
clinical status:
  coding:
    code:
      v: active
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1

1
type: Observation
id:
  v: ImFinding-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImFinding
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImFinding
text:
  status:
    v: generated
  div: Generated Narrative: Observation ImFinding-knee-mri-example Profile: Observation: Imaging Finding status: Final code: Clinical finding effective: 1993-11-29 12:36:56+0000 value: Complete tear of the ACL, which is torn in the mid substance
status:
  v: final
code:
  coding: http://snomed.info/id/363406005
    system:
      v: http://snomed.info/sct
    code:
      v: 363406005
    display:
      v: Clinical finding
effective: dateTime
  v: 1993-11-29T12:36:56+00:00
value: string
  v: Complete tear of the ACL, which is torn in the mid substance

1
type: DiagnosticReport
id:
  v: DiagnosticReport-knee-mri-example
meta:
  profile:
    v: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImDiagnosticReport
    link: http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImDiagnosticReport
text:
  status:
    v: generated
  div: Generated Narrative: DiagnosticReport DiagnosticReport-knee-mri-example Profile: DiagnosticReport: Imaging Report Imaging Report V0.0.1 (Diagnostic imaging study) Subject Not done yet Reported 2021-01-01 00:00:00+0000 Performer Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 Report Details
status:
  v: final
category:
  coding: https://loinc.org/rdf/18748-4
    system:
      v: http://loinc.org
    code:
      v: 18748-4
code:
  coding:
    system:
      v: http://hl7.eu/fhir/imaging-r5/CodeSystem/Hl7EuDocumentTypes
    code:
      v: imaging-report-v0-0-1
  coding: EXAMPLE
    system:
      v: http://loinc.org
    code:
      v: example
subject:
  link: http://hl7.eu/fhir/imaging-r5/Patient/1
  reference:
    v: Patient/1
issued:
  v: 2021-01-01T00:00:00Z
performer:
  link: http://hl7.eu/fhir/imaging-r5/Practitioner/1
  reference:
    v: Practitioner/1
composition:
  link: http://hl7.eu/fhir/imaging-r5/Composition/1
  reference:
    v: Composition/1
presented form:
  content type:
    v: application/pdf

status:
  v: generated
div: FLUID: Moderate effusion. MENISCI: Medial: No evidence of a tear. Lateral: Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. CRUCIATE LIGAMENTS: Complete tear of the ACL, which is torn in the mid substance. The posterior cruciate ligament is intact. COLLATERAL LIGAMENTS: Grade 1 to grade 2 MCL sprain. There is edema in the deep fibers, as well as some in the in the superficial fibers and in the adjacent soft tissues. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. The lateral collateral ligament complex is intact. Edema is noted in the popliteus muscle belly and muscle-tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. EXTENSOR MECHANISM: Intact. CARTILAGE: Patellofemoral compartment: No chondral defect or area of high-grade chondral loss. Medial tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. Lateral tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. BONE MARROW: Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.

link: http://hl7.eu/fhir/imaging-r5/Finding/1
reference:
  v: Finding/1

title:
  v: Impressions
code:
  coding: https://loinc.org/rdf/19005-8
    system:
      v: http://loinc.org
    code:
      v: 19005-8
    display:
      v: Impression
text:
  status:
    v: additional
  div: 1. Moderate effusion. 2. Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. 3. Complete tear of the ACL. 4. Grade 1 to grade 2 MCL complex sprain as described above. 5. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. Edema is noted in the popliteus muscle belly and muscle tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. 6. Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.
entry:
  link: http://hl7.eu/fhir/imaging-r5/Impression/1
  reference:
    v: Impression/1

title:
  v: Recommendations
code:
  coding: https://loinc.org/rdf/18783-1
    system:
      v: http://loinc.org
    code:
      v: 18783-1
    display:
      v: Recommendation
text:
  status:
    v: generated
  div: None.
empty reason:
  coding: LA4720-4
    system:
      v: http://loinc.org
    code:
      v: LA4720-4
    display:
      v: None available

title:
  v: Communications
code:
  coding: https://loinc.org/rdf/18783-1
    system:
      v: http://loinc.org
    code:
      v: 18783-1
    display:
      v: Communication
text:
  status:
    v: generated
  div: None.
empty reason:
  coding: LA4720-4
    system:
      v: http://loinc.org
    code:
      v: LA4720-4
    display:
      v: None available