HL7 Europe Imaging Report R5
1.0.0-ballot - ballot 150

This page is part of the HL7 Europe Imaging Study Report (v1.0.0-ballot: STU 1 Ballot 2) based on FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: Composition: semi-structured

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{
  "resourceType" : "Composition",
  "id" : "CompositionSemiStructured",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.eu/fhir/imaging-r5/StructureDefinition/CompositionEuImaging"
    ]
  },
  "language" : "en",
  "text" : {
    "status" : "generated"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/event-basedOn",
      "valueReference" : {
        "type" : "ServiceRequest",
        "identifier" : {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                "code" : "ACSN"
              },
              {
                "system" : "http://dicom.nema.org/resources/ontology/DCM",
                "code" : "121022",
                "display" : "Accession Number"
              }
            ]
          },
          "system" : "http://example.org/myhosptital/accessionsystem",
          "value" : "123456789"
        }
      }
    },
    {
      "url" : "http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference",
      "valueReference" : {
        🔗 "reference" : "DiagnosticReport/DiagnosticReportSemiStructured"
      }
    }
  ],
  "identifier" : [
    {
      "system" : "http://example.org/myhosptital/reportidentifiers",
      "value" : "o32u4js8492ff"
    }
  ],
  "version" : "1.0.0",
  "status" : "final",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "24802-1",
        "display" : "MR Knee"
      }
    ]
  },
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "RAD",
          "display" : "Radiologie"
        }
      ]
    },
    {
      "coding" : [
        {
          "system" : "http://loinc.org",
          "code" : "85430-7"
        }
      ]
    },
    {
      "coding" : [
        {
          "system" : "http://hl7.eu/fhir/eu-health-data-api/CodeSystem/eehrxf-document-priority-category-cs",
          "code" : "Medical-Imaging"
        }
      ]
    }
  ],
  "subject" : [
    {
      🔗 "reference" : "Patient/PatientSemiStructuredReport"
    }
  ],
  "date" : "2025-05-08",
  "author" : [
    {
      🔗 "reference" : "PractitionerRole/PractitionerRoleSemiStructuredReportAuthor"
    },
    {
      🔗 "reference" : "Organization/OrganizationSemiStructuredReport"
    }
  ],
  "title" : "Radiology Report for the left/right foot study",
  "section" : [
    {
      "title" : "Imaging Study",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18726-0"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "entry" : [
        {
          🔗 "id" : "study1-ref",
          "reference" : "ImagingStudy/ImagingStudySemiStructuredReport1"
        },
        {
          🔗 "id" : "study2-ref",
          "reference" : "ImagingStudy/ImagingStudySemiStructuredReport2"
        }
      ]
    },
    {
      "title" : "Order",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "55115-0",
            "display" : "Requested imaging studies information Document"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "emptyReason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
            "code" : "nilknown",
            "display" : "Nil Known"
          }
        ]
      }
    },
    {
      "title" : "History",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11329-0",
            "display" : "History general Narrative - Reported"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "emptyReason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
            "code" : "nilknown",
            "display" : "Nil Known"
          }
        ]
      }
    },
    {
      "title" : "Procedure",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "55111-9",
            "display" : "Current imaging procedure descriptions Document"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "emptyReason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
            "code" : "unavailable",
            "display" : "Unavailable"
          }
        ]
      }
    },
    {
      "title" : "Comparison",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18834-2",
            "display" : "Radiology Comparison study (narrative)"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "emptyReason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
            "code" : "nilknown",
            "display" : "Nil Known"
          }
        ]
      }
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/note",
          "valueAnnotation" : {
            "id" : "finding-note1",
            "text" : "Linker Fuß:\n  Allenfalls geringe Abflachung des Fußgewölbes und normale Dicke der Plantarfaszie. Regelrechte\n  Artikulation im Rückfuß, Mittelfuß und Vorfußes. Im Großzehengrundgelenk deutliche Verschmälerung des\n  Gelenkspaltes und Ausbildung von subchondralen Geröllzysten sowie deutliche postoperative\n  Veränderungen nach Umstellungsosteotomie. Die Beuge- und Strecksehnen sind intakt."
          }
        },
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/note",
          "valueAnnotation" : {
            "id" : "finding-note2",
            "text" : "Rechter Fuß:\n  Analog zur Gegenseite zeigt sich eine allenfalls geringe Abflachung des Fußgewölbes und unauffällige\n  Plantarfaszie. Normale Artikulation im Rückfuß, Mittelfußes und Vorfußes. Im Seitenvergleich rechts\n  geringere degenerative Veränderungen des Großzehengrundgelenkes. Keine Signalauffälligkeiten an den\n  Beuge- und Strecksehnen."
          }
        }
      ],
      "title" : "Findings",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59776-5",
            "display" : "Procedure findings Narrative"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "entry" : [
        {
          🔗 "reference" : "Observation/ObservationAnchor"
        }
      ]
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/note",
          "valueAnnotation" : {
            "id" : "impression-note",
            "text" : "Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links."
          }
        }
      ],
      "title" : "Impression",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "19005-8",
            "display" : "Radiology Imaging study [Impression] (narrative)"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      }
    },
    {
      "title" : "Recommendations",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18783-1",
            "display" : "Radiology Study recommendation (narrative)"
          }
        ]
      },
      "text" : {
        "status" : "generated"
      },
      "emptyReason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
            "code" : "nilknown",
            "display" : "Nil Known"
          }
        ]
      }
    }
  ]
}