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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<Composition xmlns="http://hl7.org/fhir">
  <id value="CompositionSemiStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging-r5/StructureDefinition/CompositionEuImaging"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/event-basedOn">
    <valueReference>
      <type value="ServiceRequest"/>
      <identifier>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
            <code value="ACSN"/>
          </coding>
          <coding>
            <system value="http://dicom.nema.org/resources/ontology/DCM"/>
            <code value="121022"/>
            <display value="Accession Number"/>
          </coding>
        </type>
        <system value="http://example.org/myhosptital/accessionsystem"/>
        <value value="123456789"/>
      </identifier>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/extensions/StructureDefinition/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="Radiologie"/>
    </coding>
  </category>
  <category>
    <coding>
      <system value="http://loinc.org"/>
      <code value="85430-7"/>
    </coding>
  </category>
  <category>
    <coding>
      <system
              value="http://hl7.eu/fhir/eu-health-data-api/CodeSystem/eehrxf-document-priority-category-cs"/>
      <code value="Medical-Imaging"/>
    </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>
    <text>
      <status value="generated"/>
    </text>
    <entry id="study1-ref">🔗 
      <reference value="ImagingStudy/ImagingStudySemiStructuredReport1"/>
    </entry>
    <entry id="study2-ref">🔗 
      <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>
    <text>
      <status value="generated"/>
    </text>
    <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>
    <text>
      <status value="generated"/>
    </text>
    <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>
    <text>
      <status value="generated"/>
    </text>
    <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>
    <text>
      <status value="generated"/>
    </text>
    <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 id="finding-note1">
        <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 id="finding-note2">
        <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="Procedure findings Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <entry>🔗 
      <reference value="Observation/ObservationAnchor"/>
    </entry>
  </section>
  <section>
    <extension url="http://hl7.org/fhir/StructureDefinition/note">
      <valueAnnotation id="impression-note">
        <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>
    <text>
      <status value="generated"/>
    </text>
  </section>
  <section>
    <title value="Recommendations"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18783-1"/>
        <display value="Radiology Study recommendation (narrative)"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
    </text>
    <emptyReason>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/>
        <code value="nilknown"/>
        <display value="Nil Known"/>
      </coding>
    </emptyReason>
  </section>
</Composition>