HL7 Europe Imaging Study Report
0.1.0-snapshot1 - draft 150

This page is part of the HL7 Europe Imaging Study Report (v0.1.0-snapshot1: QA Preview) based on FHIR (HL7® FHIR® Standard) v5.0.0. This version is a pre-release. The current official version is 0.1.0-ballot. For a full list of available versions, see the Directory of published versions

: Composition for the left/right foot study - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="CompositionSemiStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/ImComposition"/>
  </meta>
  <language value="de-DE"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="de-DE" lang="de-DE"><p class="res-header-id"><b>Generated Narrative: Composition CompositionSemiStructured</b></p><a name="CompositionSemiStructured"> </a><a name="hcCompositionSemiStructured"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Language: de-DE</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ImComposition.html">Composition: Imaging Report</a></p></div><p><b>Based on</b>: Identifier: accession/123456789</p><p><b>Document DiagnosticReport Reference</b>: <a href="DiagnosticReport-DiagnosticReportSemiStructured.html">Diagnostic Report for 'MR Knee' for '-&gt;Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29'</a></p><p><b>identifier</b>: <code>http://example.org/myhosptital/reportidentifiers</code>/o32u4js8492ff</p><p><b>version</b>: 1.0.0</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 24802-1}">MR Knee</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 RAD}">Radiology</span></p><p><b>date</b>: 2025-05-08</p><p><b>author</b>: </p><ul><li><a href="PractitionerRole-PractitionerRoleSemiStructuredReportAuthor.html">PractitionerRole Radiologist</a></li><li><a href="Organization-OrganizationSemiStructuredReport.html">Organization Radiology Zentrum Bremen</a></li></ul><p><b>title</b>: Radiology Report for the left/right foot study</p></div>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/event-basedOn">
    <valueReference>
      <identifier>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/v3-ActClass#v2-0203"/>
            <code value="ACSN"/>
          </coding>
        </type>
        <system value="http://example.org/myhosptital/accessionsystem"/>
        <value value="123456789"/>
      </identifier>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging-r5/StructureDefinition/im-composition-diagnosticReportReference">
    <valueReference>🔗 
      <reference value="DiagnosticReport/DiagnosticReportSemiStructured"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://example.org/myhosptital/reportidentifiers"/>
    <value value="o32u4js8492ff"/>
  </identifier>
  <version value="1.0.0"/>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="24802-1"/>
      <display value="MR Knee"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="RAD"/>
      <display value="Radiology"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/PatientSemiStructuredReport"/>
  </subject>
  <date value="2025-05-08"/>
  <author>🔗 
    <reference
               value="PractitionerRole/PractitionerRoleSemiStructuredReportAuthor"/>
  </author>
  <author>🔗 
    <reference value="Organization/OrganizationSemiStructuredReport"/>
  </author>
  <title value="Radiology Report for the left/right foot study"/>
  <section>
    <title value="Imaging Study"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18726-0"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="ImagingStudy/ImagingStudySemiStructuredReport1"/>
    </entry>
    <entry>🔗 
      <reference value="ImagingStudy/ImagingStudySemiStructuredReport2"/>
    </entry>
  </section>
  <section>
    <title value="Order"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55115-0"/>
        <display value="Requested imaging studies information Document"/>
      </coding>
    </code>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11329-0"/>
        <display value="History general Narrative - Reported"/>
      </coding>
    </code>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="Procedure"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55111-9"/>
        <display value="Current imaging procedure descriptions Document"/>
      </coding>
    </code>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="unavailable"/>
        <display value="Unavailable"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <title value="Comparison"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18834-2"/>
        <display value="Radiology Comparison study (narrative)"/>
      </coding>
    </code>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="Linker Fuß:
  Allenfalls geringe Abflachung des Fußgewölbes und normale Dicke der Plantarfaszie. Regelrechte
  Artikulation im Rückfuß, Mittelfuß und Vorfußes. Im Großzehengrundgelenk deutliche Verschmälerung des
  Gelenkspaltes und Ausbildung von subchondralen Geröllzysten sowie deutliche postoperative
  Veränderungen nach Umstellungsosteotomie. Die Beuge- und Strecksehnen sind intakt."/>
      </valueAnnotation>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="Rechter Fuß:
  Analog zur Gegenseite zeigt sich eine allenfalls geringe Abflachung des Fußgewölbes und unauffällige
  Plantarfaszie. Normale Artikulation im Rückfuß, Mittelfußes und Vorfußes. Im Seitenvergleich rechts
  geringere degenerative Veränderungen des Großzehengrundgelenkes. Keine Signalauffälligkeiten an den
  Beuge- und Strecksehnen."/>
      </valueAnnotation>
    </extension>
    <title value="Findings"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59776-5"/>
        <display value="Findings"/>
      </coding>
    </code>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation>
        <text
              value="Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links."/>
      </valueAnnotation>
    </extension>
    <title value="Impression"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="19005-8"/>
        <display value="Radiology Imaging study [Impression] (narrative)"/>
      </coding>
    </code>
  </section>
  <section>
    <title value="Recommendations"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18783-1"/>
        <display value="Radiology Study recommendation (narrative)"/>
      </coding>
    </code>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
</Composition>