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
| DiagnosticReport | I | | DiagnosticReport | There are no (further) constraints on this element Element IdShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate names Report, Test, Result, Results, Labs, Laboratory Definition The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
DiagnosticReport Constraints- dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-4:If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() - dom-6:A resource should have narrative for robust management
text.`div`.exists() - dom-5:If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
- rim:Entity. Role, or Act
- workflow:Event
- v2:ORU -> OBR
- rim:Observation[classCode=OBS, moodCode=EVN]
|
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdDiagnosticReport.identifier Business identifier for report Alternate names ReportID, Filler ID, Placer ID Definition Identifiers assigned to this report by the performer or other systems.
Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
Usually assigned by the Information System of the diagnostic service provider (filler id).
Identifier Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd:Identifier
- workflow:Event.identifier
- w5:FiveWs.identifier
- v2:OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
- rim:id
|
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | There are no (further) constraints on this element Element IdShort description What was requested Alternate names Request Definition Details concerning a service requested.
This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.basedOn
- v2:ORC? OBR-2/3?
- rim:outboundRelationship[typeCode=FLFS].target
|
| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdShort description registered | partial | preliminary | final + Definition The status of the diagnostic report.
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Binding The status of the diagnostic report. DiagnosticReportStatus (required)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- workflow:Event.status
- w5:FiveWs.status
- v2:OBR-25 (not 1:1 mapping)
- rim:statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
|
| category | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdDiagnosticReport.category Service category Alternate names Department, Sub-department, Service, Discipline Definition A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
CodeableConcept Binding Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5:FiveWs.class
- v2:OBR-24
- rim:inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
|
| coding | S Σ | 2..* | Coding | Element IdDiagnosticReport.category.coding Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| loinc | S Σ | 1..1 | Coding | Element IdDiagnosticReport.category.coding:loinc Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://loinc.org",
"code": "18726-0"
} Mappings- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:loinc.system Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:loinc.version Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:loinc.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:loinc.display Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.2 - but note this is not well followed
- rim:CV.displayName
- orim:fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:loinc.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:Sometimes implied by being first
- rim:CD.codingRationale
- orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| diagnostic-service-sections | S Σ | 1..1 | Coding | Element IdDiagnosticReport.category.coding:diagnostic-service-sections Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0074",
"code": "RAD"
} Mappings- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:diagnostic-service-sections.system Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:diagnostic-service-sections.version Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:diagnostic-service-sections.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:diagnostic-service-sections.display Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.2 - but note this is not well followed
- rim:CV.displayName
- orim:fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdDiagnosticReport.category.coding:diagnostic-service-sections.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:Sometimes implied by being first
- rim:CD.codingRationale
- orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.category.text Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.9. But note many systems use C*E.2 for this
- rim:./originalText[mediaType/code="text/plain"]/data
- orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| code | S Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdShort description Name/Code for this diagnostic report Alternate names Type Definition A code or name that describes this diagnostic report.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow:Event.code
- w5:FiveWs.what[x]
- v2:OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
- rim:code
|
| coding | S Σ | 1..* | Coding | Element IdDiagnosticReport.code.coding Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| loinc | S Σ | 1..1 | Coding | Element IdDiagnosticReport.code.coding:loinc Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://loinc.org",
"code": "18748-4"
} Mappings- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdDiagnosticReport.code.coding:loinc.system Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.code.coding:loinc.version Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdDiagnosticReport.code.coding:loinc.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.code.coding:loinc.display Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.2 - but note this is not well followed
- rim:CV.displayName
- orim:fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdDiagnosticReport.code.coding:loinc.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:Sometimes implied by being first
- rim:CD.codingRationale
- orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.code.text Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.9. But note many systems use C*E.2 for this
- rim:./originalText[mediaType/code="text/plain"]/data
- orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| subject | S Σ I | 1..1 | Reference(Patient | Group) | Element IdShort description The subject of the report - usually, but not always, the patient Alternate names Patient Definition The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.
SHALL know the subject context.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient | Group) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.subject
- w5:FiveWs.subject[x]
- v2:PID-3 (no HL7 v2 mapping for Group or Device)
- rim:participation[typeCode=SBJ]
- w5:FiveWs.subject
|
| encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdDiagnosticReport.encounter Health care event when test ordered Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
Links the request to the Encounter context.
This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Reference(Encounter) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.encounter
- w5:FiveWs.context
- v2:PV1-19
- rim:inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
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| effective[x] | S Σ | 1..1 | | There are no (further) constraints on this element Element IdDiagnosticReport.effective[x] Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence Definition The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
Need to know where in the patient history to file/present this report.
If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- workflow:Event.occurrence[x]
- w5:FiveWs.done[x]
- v2:OBR-7
- rim:effectiveTime
|
| effectiveDateTime | | | dateTime | There are no (further) constraints on this element Data Type dateTime |
| effectivePeriod | | | Period | There are no (further) constraints on this element Data Type Period |
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdShort description DateTime this version was made Alternate names Date published, Date Issued, Date Verified Definition The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.
Clinicians need to be able to check the date that the report was released.
May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
instant Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- w5:FiveWs.recorded
- v2:OBR-22
- rim:participation[typeCode=VRF or AUT].time
|
| performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element IdDiagnosticReport.performer Responsible Diagnostic Service Alternate names Laboratory, Service, Practitioner, Department, Company, Authorized by, Director Definition The diagnostic service that is responsible for issuing the report.
Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.performer.actor
- w5:FiveWs.actor
- v2:PRT-8 (where this PRT-4-Participation = "PO")
- rim:.participation[typeCode=PRF]
|
| resultsInterpreter | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | There are no (further) constraints on this element Element IdDiagnosticReport.resultsInterpreter Primary result interpreter Alternate names Analyzed by, Reported by Definition The practitioner or organization that is responsible for the report's conclusions and interpretations.
Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Might not be the same entity that takes responsibility for the clinical report.
Reference(Practitioner | PractitionerRole | Organization | CareTeam) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.performer.actor
- w5:FiveWs.actor
- v2:OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
- rim:.participation[typeCode=PRF]
|
| specimen | I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdDiagnosticReport.specimen Specimens this report is based on Definition Details about the specimens on which this diagnostic report is based.
Need to be able to report information about the collected specimens on which the report is based.
If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Reference(Specimen) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2:SPM
- rim:participation[typeCode=SBJ]
|
| result | I | 0..* | Reference(Observation) | There are no (further) constraints on this element Element IdShort description Observations Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Observations can contain observations.
Reference(Observation) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2:OBXs
- rim:outboundRelationship[typeCode=COMP].target
|
| imagingStudy | I | 0..* | Reference(ImagingStudy) | There are no (further) constraints on this element Element IdDiagnosticReport.imagingStudy Reference to full details of imaging associated with the diagnostic report Definition One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Reference(ImagingStudy) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim:outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
|
| media | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdShort description Key images associated with this report Alternate names DICOM, Slides, Scans Definition A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Many diagnostic services include images in the report as part of their service.
BackboneElement Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:OBX?
- rim:outboundRelationship[typeCode=COMP].target
|
| link | Σ I | 1..1 | Reference(Media) | There are no (further) constraints on this element Element IdDiagnosticReport.media.link Reference to the image source Definition Reference to the image source.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Media) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim:.value.reference
|
| conclusion | | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.conclusion Clinical conclusion (interpretation) of test results Alternate names Report Definition Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
Need to be able to provide a conclusion that is not lost among the basic result data.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:OBX
- rim:inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
|
| conclusionCode | S | 1..1 | CodeableConceptBinding | Element IdDiagnosticReport.conclusionCode Codes for the clinical conclusion of test results Definition One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Diagnosis codes provided as adjuncts to the report. RadiologicFindings (preferred)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2:OBX
- rim:inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
|
| coding | S Σ | 1..* | Coding | Element IdDiagnosticReport.conclusionCode.coding Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| snomed | S Σ | 1..1 | Coding | Element IdDiagnosticReport.conclusionCode.coding:snomed Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://snomed.info/sct"
} Mappings- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
- v2:C*E.1-8, C*E.10-22
- rim:union(., ./translation)
- orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.coding:snomed.system Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.coding:snomed.version Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.coding:snomed.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.coding:snomed.display Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.2 - but note this is not well followed
- rim:CV.displayName
- orim:fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.coding:snomed.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:Sometimes implied by being first
- rim:CD.codingRationale
- orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDiagnosticReport.conclusionCode.text Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.9. But note many systems use C*E.2 for this
- rim:./originalText[mediaType/code="text/plain"]/data
- orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| presentedForm | I | 0..* | Attachment | There are no (further) constraints on this element Element IdDiagnosticReport.presentedForm Entire report as issued Definition Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.
"application/pdf" is recommended as the most reliable and interoperable in this context.
Attachment Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - att-1:If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()
- rim:n/a
- v2:ED/RP
- rim:ED
- v2:OBX
- rim:text (type=ED)
|
ValueSets
The conclusionCode valueset is provided with SNOMED-CT codes.
Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/radiology-findings
ValueSet 'RadiologicFindings'
| Version | 1.0.6 |
| Published by | Berlin Institute of Health at Charité (BIH) |
| Status | Active |
| Experimental | False |
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"
}