Radiological findings


Parameter Case Report Form and Response Options

Radiological findings
Undetermined finding
COVID-19-characteristic finding
Normal finding

This profile of a FHIR DiagnosticReport is aligned with the DiagnosticReport Laboratory-profile of the Medical Informatics Initiative (MII).

DiagnosticReport.category is set to match radiology.

DiagnosticReport.code shall be coded as LOINC 18748-4 Diagnostic imaging study.

DiagnosticReport.conclusionCode contains a valueset binding with SNOMED-CT codes for the possible case report form response options.


Profile - Diagnostic Report Radiology

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/diagnostic-report-radiology

Snapshot

identifierΣ0..*Identifier
basedOnI0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
statusΣ ?!1..1codeBinding
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
issuedΣ0..1instant
performerΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
resultsInterpreterΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
specimenI0..*Reference(Specimen)
resultI0..*Reference(Observation)
imagingStudyI0..*Reference(ImagingStudy)
comment0..1string
conclusion0..1string
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
presentedFormI0..*Attachment


ValueSets

The conclusionCode valueset is provided with SNOMED-CT codes.


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/radiology-findings

ValueSet 'RadiologicFindings'

Version1.0.6
Published byBerlin Institute of Health at Charité (BIH)
StatusActive
ExperimentalFalse

Radiology findings in the context of Covid-19

Contact Information

Website: https://www.bihealth.org/en/re...

This value set includes codes from the following code systems:


CodeSystem Supplement

There is a CodeSystem supplement for postcoordinated SNOMED expressions.

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/CodeSystem/snomed-pce-supplement

{
    "resourceType": "CodeSystem",
    "status": "active",
    "content": "supplement",
    "name": "SNOMEDsupplement",
    "id": "snomed-pce-supplement",
    "title": "SNOMED Supplement CodeSystem",
    "description": "CodeSystem supplement for SNOMED CT post-coordinated expressions.",
    "version": "1.0.6",
    "url": "https://www.netzwerk-universitaetsmedizin.de/fhir/CodeSystem/snomed-pce-supplement",
    "concept":  [
        {
            "code": "118247008| Radiologic finding|:{363713009| Has interpretation|=373068000| Undetermined|}",
            "display": "Radiological finding of undetermined significance"
        },
        {
            "code": "118247008| Radiologic finding|:{363713009| Has interpretation|=263654008| Abnormal|,42752001| Due to|=840539006| COVID-19|}",
            "display": "Radiological finding characteristic for COVID-19"
        },
        {
            "code": "118247008| Radiologic finding|:{363713009| Has interpretation|=17621005| Normal|}",
            "display": "Radiological finding normal"
        },
        {
            "code": "396332003+414029004",
            "display": "Rheumatological/immunological disease"
        },
        {
            "code": "836498007+836388000",
            "display": "Vaccine product containing Mumps orthorubulavirus antigen (medicinal product) + Vaccine product containing Rubella virus antigen (medicinal product)"
        },
        {
            "code": "871729003+836380007+601000221108+863911006+836374004+871871008",
            "display": "Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) + Vaccine product containing only Neisseria meningitidis serogroup A and C antigens (medicinal product)"
        },
        {
            "code": "871729003+836380007+601000221108+863911006+836374004",
            "display": "Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product)"
        },
        {
            "code": "871729003+836374004+863911006",
            "display": "Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product)"
        },
        {
            "code": "863911006+836374004+601000221108+836381006",
            "display": "Vaccine product containing Clostridium tetani antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) + Vaccine product containing Corynebacterium diphtheriae antigen (medicinal product)"
        },
        {
            "code": "836380007+1031000221108",
            "display": "Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Human poliovirus antigen (medicinal product)"
        },
        {
            "code": "871729003+836388000+863911006",
            "display": "Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Rubella virus antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product)"
        },
        {
            "code": "836382004+836388000",
            "display": "Vaccine product containing Measles morbillivirus antigen (medicinal product) + Vaccine product containing Rubella virus antigen (medicinal product)"
        },
        {
            "code": "836498007+836382004",
            "display": "Vaccine product containing Mumps orthorubulavirus antigen (medicinal product) + Vaccine product containing Measles morbillivirus antigen (medicinal product)"
        },
        {
            "code": "836398006+836380007",
            "display": "Vaccine product containing Streptococcus pneumoniae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product)"
        },
        {
            "code": "836380007+601000221108",
            "display": "Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product)"
        },
        {
            "code": "836383009+836390004",
            "display": "Vaccine product containing Vibrio cholerae antigen (medicinal product) + Vaccine product containing Salmonella enterica subspecies enterica serovar Typhi antigen (medicinal product)"
        }
    ],
    "experimental": false,
    "publisher": "Berlin Institute of Health at Charité (BIH)",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.bihealth.org/en/research/core-facilities/interoperability/"
                }
            ]
        }
    ],
    "date": "2021-09-20",
    "supplements": "http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20220131"
}


Examples

Radiology Report Covid-19 finding
Example diagnostic report with positive finding

{
    "resourceType": "DiagnosticReport",
    "id": "diagnostic-report-radiology-covid-19",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/diagnostic-report-radiology"
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "18726-0",
                    "system": "http://loinc.org",
                    "display": "Radiology studies (set)"
                },
                {
                    "code": "RAD",
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "display": "Radiology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "18748-4",
                "system": "http://loinc.org",
                "display": "Diagnostic imaging study"
            }
        ]
    },
    "conclusionCode":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "118247008:{363713009=263654008,42752001=840539006}",
                    "display": "|Radiologic finding (finding)|:{|Has interpretation (attribute)|=|Abnormal (qualifier value)|,|Due to (attribute)|=|Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder)|}"
                }
            ]
        }
    ],
    "status": "final",
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "effectiveDateTime": "2020-09-30",
    "conclusion": "COVID-19-typischer Befund"
}


Radiology Report finding undetermined
Example diagnostic report where finding is undetermined

{
    "resourceType": "DiagnosticReport",
    "id": "diagnostic-report-radiology-undetermined",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/diagnostic-report-radiology"
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "18726-0",
                    "system": "http://loinc.org",
                    "display": "Radiology studies (set)"
                },
                {
                    "code": "RAD",
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "display": "Radiology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "18748-4",
                "system": "http://loinc.org",
                "display": "Diagnostic imaging study"
            }
        ]
    },
    "conclusionCode":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "118247008:{363713009=373068000}",
                    "display": "|Radiologic finding (finding)|:|Has interpretation (attribute)|=|Undetermined (qualifier value)|"
                }
            ]
        }
    ],
    "status": "final",
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "effectiveDateTime": "2020-09-30",
    "conclusion": "Unspezifischer Befund"
}


Radiology Report finding normal
Example diagnostic report where finding is normal

{
    "resourceType": "DiagnosticReport",
    "id": "diagnostic-report-radiology-normal",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/diagnostic-report-radiology"
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "18726-0",
                    "system": "http://loinc.org",
                    "display": "Radiology studies (set)"
                },
                {
                    "code": "RAD",
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "display": "Radiology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "18748-4",
                "system": "http://loinc.org",
                "display": "Diagnostic imaging study"
            }
        ]
    },
    "conclusionCode":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "118247008:{363713009=17621005}",
                    "display": "|Radiologic finding (finding)|:|Has interpretation (attribute)|=|Normal (qualifier value)|"
                }
            ]
        }
    ],
    "status": "final",
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "effectiveDateTime": "2020-09-30",
    "conclusion": "Normalbefund"
}