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

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
identifierΣ0..*Identifier
basedOn0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
statusΣ ?!1..1codeBinding
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ1..1Reference(Patient | Group)
encounterΣ0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
issuedΣ0..1instant
performerΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
resultsInterpreterΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
specimen0..*Reference(Specimen)
result0..*Reference(Observation)
imagingStudy0..*Reference(ImagingStudy)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
comment0..1string
conclusion0..1string
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
presentedForm0..*Attachment


ValueSets

The conclusionCode valueset is provided with SNOMED-CT codes.


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

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"
]
},
{
"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"
}
]
},
{
"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"
]
},
{
"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"
}
]
},
{
"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"
]
},
{
"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"
}
]
},
{
"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"
}