EHDS refined base model for Medical Imaging Result Report

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Identifies the type of document at hand, e.g. Discharge report.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

eHN Guideline IMG (v1.1): A.1.8.11

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.

eHN Guideline IMG (v1.1): A.1.3

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

eHN Guideline IMG (v1.1): A.1.4

Imaging Report structured body

Order Information (Imaging Result Report could respond to multiple orders).

eHN Guideline IMG (v1.1): A.2

Identifier(s) of the imaging service order.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded or structured form.

SNOMED CT

eHN Guideline IMG (v1.1): A.3.1, A3.2

Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.

eHN Guideline IMG (v1.1): A.3.3

This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.

eHN Guideline IMG (v1.1): A3.2?

Clinical findings and other observations (e.g., height and weights of the patient).

Conditions that may influence the service or result interpretation.

Medication administered before ordering the service.

List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).

Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).

Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.

HL7 sex-parameter-for-clinical-use

Any other type of relevant supporting information

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

eHN Guideline IMG (v1.1): A.4

Specification of requested service(s).

Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.

eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition

Effective dose - sum of equivalent doses to all organs, from external and/or internal exposures, each adjusted to account for the sensitivity of the organ to radiation. [mSv]

UCUM (for units)

Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

Equivalent dose is a measure of the radiation dose to tissue where an attempt has been made to allow for the different relative biological effects of different types of ionizing radiation. Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

UCUM (for units)

Type of the tissue for which do dosage was enumerated.

SNOMED CT

Examination report content.

eHN Guideline IMG (v1.1): A.5

Imaging modality (or modalities) used during imaging investigation (DICOM CID029).

DICOM Modality

eHN Guideline IMG (v1.1): A.5.1.1

All body parts investigated

eHN Guideline IMG (v1.1): A.5.1.6

Imaging procedure performed during imaging study.

eHN Guideline IMG (v1.1): A.5.1.2-A.5.1.9

Information about medication administered (contrast, sedation, stress agents), etc.

eHN Guideline IMG (v1.1): A.5.2

Adverse reactions manifested during imaging investigation.

eHN Guideline IMG (v1.1): A.5.3

Imaging report result data

eHN Guideline IMG (v1.1): A.5.4

Comments and narrative representation of the observation results and findings.

Observation details (report could consist of multiple observations)

eHN Guideline IMG (v1.1): A.5.4.1, A.5.4.3

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

eHN Guideline IMG (v1.1): A.5.5

Narrative description of the clinical conclusion (impression).

eHN Guideline IMG (v1.1): A.5.5.1

Condition or finding from imaging investigation.

eHN Guideline IMG (v1.1): A.5.5.2

Recommendations for additional imaging tests or other actions

eHN Guideline IMG (v1.1): A.5.6

Narrative description of the recommended activities including additional test, medication etc.

eHN Guideline IMG (v1.1): A.5.6.1

A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.

eHN Guideline IMG (v1.1): A.5.6.2

Documentation (reference) of a prior Imaging Report to which the current images were compared.

eHN Guideline IMG (v1.1): A.7

Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

eHN Guideline IMG (v1.1): A.6

Report attachments data elements

EHDS refined base model for Medical Imaging Result Report

Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

eHN Guideline IMG (v1.1): A.1.8.11

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.

eHN Guideline IMG (v1.1): A.1.3

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

eHN Guideline IMG (v1.1): A.1.4

Imaging Report structured body

Order Information (Imaging Result Report could respond to multiple orders).

eHN Guideline IMG (v1.1): A.2

Identifier(s) of the imaging service order.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded or structured form.

SNOMED CT

eHN Guideline IMG (v1.1): A.3.1, A3.2

Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.

eHN Guideline IMG (v1.1): A.3.3

This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.

eHN Guideline IMG (v1.1): A3.2?

Clinical findings and other observations (e.g., height and weights of the patient).

Conditions that may influence the service or result interpretation.

Medication administered before ordering the service.

List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).

Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).

Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.

HL7 sex-parameter-for-clinical-use

Any other type of relevant supporting information

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

eHN Guideline IMG (v1.1): A.4

Specification of requested service(s).

Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.

eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition

Effective dose - sum of equivalent doses to all organs, from external and/or internal exposures, each adjusted to account for the sensitivity of the organ to radiation. [mSv]

UCUM (for units)

Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

Equivalent dose is a measure of the radiation dose to tissue where an attempt has been made to allow for the different relative biological effects of different types of ionizing radiation. Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

UCUM (for units)

Type of the tissue for which do dosage was enumerated.

SNOMED CT

Examination report content.

eHN Guideline IMG (v1.1): A.5

Imaging modality (or modalities) used during imaging investigation (DICOM CID029).

DICOM Modality

eHN Guideline IMG (v1.1): A.5.1.1

All body parts investigated

eHN Guideline IMG (v1.1): A.5.1.6

Imaging procedure performed during imaging study.

eHN Guideline IMG (v1.1): A.5.1.2-A.5.1.9

Information about medication administered (contrast, sedation, stress agents), etc.

eHN Guideline IMG (v1.1): A.5.2

Adverse reactions manifested during imaging investigation.

eHN Guideline IMG (v1.1): A.5.3

Imaging report result data

eHN Guideline IMG (v1.1): A.5.4

Comments and narrative representation of the observation results and findings.

Observation details (report could consist of multiple observations)

eHN Guideline IMG (v1.1): A.5.4.1, A.5.4.3

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

eHN Guideline IMG (v1.1): A.5.5

Narrative description of the clinical conclusion (impression).

eHN Guideline IMG (v1.1): A.5.5.1

Condition or finding from imaging investigation.

eHN Guideline IMG (v1.1): A.5.5.2

Recommendations for additional imaging tests or other actions

eHN Guideline IMG (v1.1): A.5.6

Narrative description of the recommended activities including additional test, medication etc.

eHN Guideline IMG (v1.1): A.5.6.1

A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.

eHN Guideline IMG (v1.1): A.5.6.2

Documentation (reference) of a prior Imaging Report to which the current images were compared.

eHN Guideline IMG (v1.1): A.7

Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

eHN Guideline IMG (v1.1): A.6

Report attachments data elements

EHDS refined base model for Medical Imaging Result Report

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Identifies the type of document at hand, e.g. Discharge report.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

Accession number - an identifier, managed by the RIS at the local level, which usually uniquely identifies an imaging procedure request, and links it to imaging study(ies) and related imaging report(s). As it is prefixed by the registration authority it is a globally unique ID, usable both nationally and cross-border.

eHN Guideline IMG (v1.1): A.1.8.11

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.

eHN Guideline IMG (v1.1): A.1.3

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

eHN Guideline IMG (v1.1): A.1.4

Imaging Report structured body

Order Information (Imaging Result Report could respond to multiple orders).

eHN Guideline IMG (v1.1): A.2

Identifier(s) of the imaging service order.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded or structured form.

SNOMED CT

eHN Guideline IMG (v1.1): A.3.1, A3.2

Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.

eHN Guideline IMG (v1.1): A.3.3

This information includes diagnosis, clinical findings and other observations. This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the metal implants present in patient's body.

eHN Guideline IMG (v1.1): A3.2?

Clinical findings and other observations (e.g., height and weights of the patient).

Conditions that may influence the service or result interpretation.

Medication administered before ordering the service.

List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants).

Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown).

Sex parameter for clinical use - provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population.

HL7 sex-parameter-for-clinical-use

Any other type of relevant supporting information

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

eHN Guideline IMG (v1.1): A.4

Specification of requested service(s).

Information on total exposure to ionising radiation. This information is required by regulations in several EU countries.

eHN Guideline IMG (v1.1): B.1.4.4, Article 2 Imaging report definition

Effective dose - sum of equivalent doses to all organs, from external and/or internal exposures, each adjusted to account for the sensitivity of the organ to radiation. [mSv]

UCUM (for units)

Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

Equivalent dose is a measure of the radiation dose to tissue where an attempt has been made to allow for the different relative biological effects of different types of ionizing radiation. Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv].

UCUM (for units)

Type of the tissue for which do dosage was enumerated.

SNOMED CT

Examination report content.

eHN Guideline IMG (v1.1): A.5

Imaging modality (or modalities) used during imaging investigation (DICOM CID029).

DICOM Modality

eHN Guideline IMG (v1.1): A.5.1.1

All body parts investigated

eHN Guideline IMG (v1.1): A.5.1.6

Imaging procedure performed during imaging study.

eHN Guideline IMG (v1.1): A.5.1.2-A.5.1.9

Information about medication administered (contrast, sedation, stress agents), etc.

eHN Guideline IMG (v1.1): A.5.2

Adverse reactions manifested during imaging investigation.

eHN Guideline IMG (v1.1): A.5.3

Imaging report result data

eHN Guideline IMG (v1.1): A.5.4

Comments and narrative representation of the observation results and findings.

Observation details (report could consist of multiple observations)

eHN Guideline IMG (v1.1): A.5.4.1, A.5.4.3

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

eHN Guideline IMG (v1.1): A.5.5

Narrative description of the clinical conclusion (impression).

eHN Guideline IMG (v1.1): A.5.5.1

Condition or finding from imaging investigation.

eHN Guideline IMG (v1.1): A.5.5.2

Recommendations for additional imaging tests or other actions

eHN Guideline IMG (v1.1): A.5.6

Narrative description of the recommended activities including additional test, medication etc.

eHN Guideline IMG (v1.1): A.5.6.1

A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.

eHN Guideline IMG (v1.1): A.5.6.2

Documentation (reference) of a prior Imaging Report to which the current images were compared.

eHN Guideline IMG (v1.1): A.7

Metadata of the DICOM study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

eHN Guideline IMG (v1.1): A.6

Report attachments data elements