Generated Narrative: StructureDefinition EHDSImagingReport Name Flags Card. Type Description & Constraints <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport" title="Imaging report reflects the observations and interpretations of one or more imaging studies, contains elements such as the reason why the study is requested, relevant contextual medical information, the modality used to acquire images and its settings, procedures and body localisations that were used, a description of the observations and findings, exposure information, conclusion and advice.">EHDSImagingReport 0..* EHDSDocument Elements defined in Ancestors:header, header, presentedForm Imaging report model Instances of this logical model can be the target of a Reference #xD; header 1..1 Base Imaging Report header #xD; authorship 1..* Base Report authoring details #xD; author[x] 1..1 EHDSHealthProfessional, EHDSOrganisation, EHDSDevice Author by whom the document was/were authored. Multiple authors could be provided. #xD; status 1..1 CodeableConcept Status of the document #xD; documentType 1..1 CodeableConcept Type of document (code for medical imaging report) #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.header.accessionNumber" title="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.">accessionNumber 0..1 string 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. #xD; healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information #xD; intendedRecipient[x] 0..* 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 #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; intendedRecipientEHDSDevice EHDSDevice #xD; body 0..1 Base Imaging Report structured body #xD; orderInformation 0..* Base Order Information (Imaging Result Report could respond to multiple orders). #xD; orderId 1..* Identifier Identifier(s) of the imaging service order. #xD; orderDateAndTime 0..1 dateTime Date and time of the order placement. #xD; orderPlacer[x] 0..1 The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself. #xD; orderPlacerEHDSHealthProfessional EHDSHealthProfessional #xD; orderPlacerEHDSOrganisation EHDSOrganisation #xD; orderPlacerEHDSPatient EHDSPatient #xD; orderReasonText 0..* string An explanation or justification for why this service is being requested in textual form. #xD; orderReason[x] 0..* An explanation or justification for why this service is being requested in coded or structured form. Binding Description: (preferred): SNOMED CT #xD; orderReasonCodeableConcept CodeableConcept #xD; orderReasonEHDSCondition EHDSCondition #xD; orderReasonEHDSObservation EHDSObservation #xD; clinicalQuestion 0..1 string Specification of clinical question (goal of the investigation) to be answered by the imaging investigation. #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.body.supportingInformation" title="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.">supportingInformation 0..1 Base Additional clinical information about the patient or specimen that may affect service delivery or interpretation. #xD; observation 0..* EHDSObservation Clinical findings and other observations (e.g., height and weights of the patient). #xD; condition 0..* EHDSCondition Conditions that may influence the service or result interpretation. #xD; medicationAdministration 0..* EHDSMedicationAdministration Medication administered before ordering the service specifically for this procedure. #xD; devices 0..* EHDSDevice List of implants or devices that affect the course of the examination or its interpretation (e.g. metal implants). #xD; pregnancyStatus 0..1 EHDSCurrentPregnancy Pregnancy status when the imaging examination was performed (e.g., pregnant, not pregnant, unknown). #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.body.supportingInformation.sexForClinicalUse" title="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.">sexForClinicalUse 0..* CodeableConcept 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. Binding Description: (preferred): HL7 sex-parameter-for-clinical-use #xD; otherSupportingInformation 0..* Resource Any other type of relevant supporting information #xD; specimen 0..* EHDSSpecimen Specimen information. Note: A specimen (not attached to a body) can be used for diagnostic, forensic and medical research purposes. #xD; serviceRequest 0..* EHDSServiceRequest Specification of requested service(s). #xD; exposureInformation 0..1 Base Information on total exposure to ionising radiation. This information is required by regulations in several EU countries. #xD; effectiveDose 0..* Quantity 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] Binding Description: (preferred): UCUM (for units) #xD; equivalentDoseInformation 1..1 Base Equivalent dose is based on the absorbed dose per organ, adjusted to account for the effectiveness of the type of radiation [mSv]. #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.body.exposureInformation.equivalentDoseInformation.equivalentDose" title="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].">equivalentDose 1..1 Quantity 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]. Binding Description: (preferred): UCUM (for units) #xD; tissueType 1..1 CodeableConcept Type of the tissue for which do dosage was enumerated. Binding Description: (preferred): SNOMED CT #xD; examinationReport 1..1 Base Examination report content. #xD; modality 1..* CodeableConcept Imaging modality (or modalities) used during imaging investigation (DICOM CID029). Binding Description: (preferred): DICOM Modality #xD; bodyPart 0..* EHDSBodyStructure All body parts investigated #xD; imagingProcedures 0..* EHDSProcedure Imaging procedure performed during imaging study. #xD; medication 0..* EHDSMedicationAdministration Information about medication administered (contrast, sedation, stress agents), etc. #xD; adverseReaction 0..* EHDSAllergyIntolerance Adverse reactions manifested during imaging investigation. #xD; resultData 0..1 Base Imaging report result data #xD; resultText 1..1 string Comments and narrative representation of the observation results and findings. #xD; observationResults 0..* EHDSObservation Observation details (report could consist of multiple observations) #xD; conclusion 1..1 Base A concise and clinically contextualised summary including interpretation/impression of the diagnostic report. #xD; impression 1..1 string Narrative description of the clinical conclusion (impression). #xD; conditionOrFinding[x] 0..* Condition or finding from imaging investigation. #xD; conditionOrFindingEHDSCondition EHDSCondition #xD; conditionOrFindingEHDSObservation EHDSObservation #xD; recommendation 0..1 Base Recommendations for additional imaging tests or other actions #xD; description 1..1 string Narrative description of the recommended activities including additional test, medication etc. #xD; carePlan 0..* EHDSCarePlan A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan. #xD; comparisonStudy 0..* EHDSImagingReport Documentation (reference) of a prior Imaging Report to which the current images were compared. #xD; <a href="StructureDefinition-EHDSImagingReport-definitions.html#EHDSImagingReport.dicomStudyMetadata" title="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.">dicomStudyMetadata 0..* EHDSImagingStudy 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. #xD; attachments[x] 0..* Report attachments data elements #xD; attachmentsEHDSAttachment EHDSAttachment #xD; attachmentsEHDSMedia EHDSMedia #xD; Documentation for this format
Imaging report reflects the observations and interpretations of one or more imaging studies, contains elements such as the reason why the study is requested, relevant contextual medical information, the modality used to acquire images and its settings, procedures and body localisations that were used, a description of the observations and findings, exposure information, conclusion and advice.
Common header for all patient-related data
Author by whom the document was/were authored. Multiple authors could be provided.
Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Date and time of the last update to the resource (may be used for technical corrections).
Reason for the current status of the resource.
Language in which the resource is written. Language is expressed by the IETF language tag.
Type of document (code for medical imaging report)
Type of document at hand, e.g. 60591-5 Patient summary document.
Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'
Time of service that is being documented
Attester who validated the document. Mulitple attesters could be provided.
Date and time of the approval of the document by Attester.
The person taking responsibility for the medical content of the document
Date and time when the document was authorised.
Categorisation 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 between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
Level of confidentiality of the document. Implicit value is normal.
A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
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.
Health insurance and payment information
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
Order Information (Imaging Result Report could respond to multiple orders).
Identifier(s) of the imaging service order.
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.
Specification of clinical question (goal of the investigation) to be answered by the imaging investigation.
Additional clinical information about the patient or specimen that may affect service delivery or interpretation.
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.
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 specifically for this procedure.
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.
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.
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]
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].
Type of the tissue for which do dosage was enumerated.
Imaging modality (or modalities) used during imaging investigation (DICOM CID029).
Imaging procedure performed during imaging study.
Information about medication administered (contrast, sedation, stress agents), etc.
Adverse reactions manifested during imaging investigation.
Comments and narrative representation of the observation results and findings.
Observation details (report could consist of multiple observations)
A concise and clinically contextualised summary including interpretation/impression of the diagnostic report.
Narrative description of the clinical conclusion (impression).
Condition or finding from imaging investigation.
Recommendations for additional imaging tests or other actions
Narrative description of the recommended activities including additional test, medication etc.
A complex and structured information about recommended goals, activities and objectives in the form of one or more formal care plan.
Documentation (reference) of a prior Imaging Report to which the current images were compared.
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.