HL7 Europe Imaging Report R4
1.0.0-alpha - qa-preview 150

This page is part of the HL7 Europe Imaging Report (v1.0.0-alpha: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0-ballot. For a full list of available versions, see the Directory of published versions

: DiagnosticReport: structured report

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="DiagnosticReportStructured"/>
  <meta>
    <profile
             value="http://hl7.eu/fhir/imaging/StructureDefinition/DiagnosticReportEuImaging"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="extensions"/>
  </text>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/AnatomicalRegionExtension">
    <valueCodeableConcept>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="67734004"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-000000000001"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-000000000008"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-000000000009"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-00000000000a"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/HL7IDRPatientHistory">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-00000000000b"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Stress Findings**
Normal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Right Ventricle**
The right ventricle is not well visualized. There is mild right ventricular hypertrophy."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Atria**
A patent foramen ovale is present and there is low risk for embolism. The left atrium is small."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="Mitral Valve
The mitral valve leaflets appear normal. There is no evidence of stenosis, fluttering, or prolapse. Mitral valve prolapse cannot be excluded. No significant mitral valve stenosis. The mitral regurgitant jet is posteriorly directed, which is consistent with anterior leaflet pathology. There is a porcine mitral valve."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Tricuspid Valve**
The tricuspid valve leaflets are thickened and/or calcified, but open well. There is a ruptured tricuspid valve chordae with a flail free wall leaflet. No significant tricuspid stenosis. There is mild to moderate tricuspid regurgitation. The prosthetic tricuspid valve is not well visualized."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Aortic Valve**
The aortic valve is trileaflet. The aortic valve is normal in structure and function. Cannot exclude aortic valvular vegetation. Hemodynamically significant valvular aortic stenosis cannot be excluded. No aortic regurgitation is present. The prosthetic aortic valve is not well visualized."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Pulmonic Valve**
The pulmonic valve is normal in structure and function. A pulmonic valvular vegetation cannot be excluded. Infundibular pulmonic stenosis is noted. There is no pulmonic valvular regurgitation. The prosthetic pulmonic valve is well‐seated."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Vessels**
The aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note">
    <valueAnnotation>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/annotationType">
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59776-5"/>
            <display value="Procedure findings Narrative"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <text
            value="**Pericardium**
There is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion."/>
    </valueAnnotation>
  </extension>
  <extension
             url="http://hl7.eu/fhir/imaging/StructureDefinition/HL7IDRRecommendation">
    <valueReference>
      <reference value="urn:uuid:11111111-2222-4333-8444-000000000031"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://example.org/myhosptital/reportidentifiers"/>
    <value value="dfkjewoieoijwoskdjf"/>
  </identifier>
  <basedOn>
    <type value="ServiceRequest"/>
    <identifier>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
          <code value="ACSN"/>
        </coding>
      </type>
      <system value="http://example.org/myhosptital/accessionsystem"/>
      <value value="87654321"/>
    </identifier>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="CUS"/>
      <display value="Cardiac Ultrasound"/>
    </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>
  <category>
    <coding>
      <system value="http://loinc.org"/>
      <code value="85430-7"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://www.ama-assn.org/go/cpt"/>
      <code value="93351"/>
      <display value="STRESS TTE COMPLETE"/>
    </coding>
  </code>
  <subject>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000003"/>
  </subject>
  <effectiveDateTime value="2003-06-01"/>
  <performer>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000007"/>
  </performer>
  <resultsInterpreter>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000005"/>
  </resultsInterpreter>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000000d"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000000e"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000000f"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000010"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000011"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000012"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000013"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000014"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000015"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000016"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000018"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000019"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001a"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001b"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001c"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001d"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001e"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000001f"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000020"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000021"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000022"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000023"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000024"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000025"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000026"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000027"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000029"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000002a"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000002b"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000002c"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000002d"/>
  </result>
  <result>
    <reference value="urn:uuid:11111111-2222-4333-8444-00000000002e"/>
  </result>
  <imagingStudy>
    <reference value="urn:uuid:11111111-2222-4333-8444-000000000004"/>
  </imagingStudy>
  <media>
    <comment value="Rest"/>
    <link>
      <reference value="urn:uuid:11111111-2222-4333-8444-00000000002f"/>
    </link>
  </media>
  <media>
    <comment value="Stress"/>
    <link>
      <reference value="urn:uuid:11111111-2222-4333-8444-000000000030"/>
    </link>
  </media>
  <conclusion
              value="This was a normal stress echocardiogram.
Nothing wrong with this patient
See you next year."/>
  <presentedForm>
    <contentType value="application/pdf"/>
    <language value="de-DE"/>
    <url value="urn:uuid:11111111-2222-4333-8444-000000000032"/>
  </presentedForm>
</DiagnosticReport>