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

Example report with renderable content and minimal metadata

Renderable format with minimal metadata

This example addresses representing a imaging report that has the minimal amount of the structured data.

The structure of this report is illustrated in the figure below.

This example corresponds to the Renderable format with minimal metadata data format.

The report is represented as a DocumentReference resource following the profile DocumentReferenceImagingReport. It refers to a Patient and to an Organization resource that represents the custodian of the document.

Resources used in this example:

• DocumentReference: wrapper resource used for indexing and retrieval metadata; its content.attachment.url points to the report bundle.
• Bundle: collection bundle that groups the core report resources for exchange.
• DiagnosticReport: main clinical report resource carrying report metadata and references to study/order as identifiers.
• Patient: subject of the report.
• Organization: reporting/custodian organization metadata.
• Binary: PDF payload referenced from DiagnosticReport.presentedForm.

The full DocumentReference resource is presented below.

{
  "resourceType" : "DocumentReference",
  "id" : "RenderableFormatWithBasicMetadata",
  ...
  "language" : "en",
  ...
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://dicom.nema.org/resources/ontology/DCM",
            "code" : "CT"
          }
        ]
      }
    },
    {
      "extension" : [
        {
          "url" : "concept",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "774007"
              },
              {
                "system" : "http://snomed.info/sct",
                "code" : "38266002"
              }
            ]
          }
        }
      ],
      "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.bodySite"
    }
  ],
  "masterIdentifier" : {
    "use" : "usual",
    "system" : "urn:ietf:rfc:3986",
    "value" : "http://unstructured-report.example.com"
  },
  "status" : "current",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "85430-7",
        "display" : "Diagnostic imaging report - example sections and entries"
      }
    ]
  },
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://hl7.eu/fhir/eu-health-data-api/CodeSystem/eehrxf-document-priority-category-cs",
          "code" : "Medical-Imaging"
        }
      ]
    }
  ],
  "subject" : {
    🔗 "reference" : "Patient/PatientUnstructuredReport"
  },
  "date" : "2024-01-01T00:00:00Z",
  "custodian" : {
    🔗 "reference" : "Organization/OrganizationUnstructuredReport"
  },
  "content" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.eu/fhir/imaging/StructureDefinition/im-documentreference-content-profile",
          "valueCanonical" : "http://hl7.eu/fhir/imaging/StructureDefinition/BundleReportMinimalMetadataEuImaging"
        }
      ],
      "attachment" : {
        "contentType" : "application/fhir+json",
        "language" : "de",
        "url" : "./Bundle/bundle-report-minimal-metadata-unstructured",
        "creation" : "2024-01-01T00:00:00Z"
      }
    }
  ]
}