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Packagehl7.fhir.eu.imaging-r4
Resource TypeDiagnosticReport
IdDiagnosticReport-DiagnosticReportSemiStructured.json
FHIR VersionR4

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Resources that this resource uses

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Narrative

Note: links and images are rebased to the (stated) source

Id: DiagnosticReportSemiStructured
Code:

MR Knee ( http://loinc.org: 24802-1 )

Identifier:

http://example.org/myhosptital/reportidentifiers: o32u4js8492ff

BasedOn: Identifier: Accession ID/123456789
Status: final
Category:

Radiology ( http://terminology.hl7.org/CodeSystem/v2-0074: RAD )

Subject: Frau GuteFrage Test-Schusti(official) (no stated gender), DoB: 1976-04-29
Period: 2025-05-08
Performer:

Organization Radiology Zentrum Bremen

Results Interpreter:

PractitionerRole Radiologist

Conclusion: Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links.
Presented form:
  • application/pdf @ ./Binary/semi-structured-pdf

Source1

{
  "resourceType": "DiagnosticReport",
  "id": "DiagnosticReportSemiStructured",
  "meta": {
    "profile": [
      "http://hl7.eu/fhir/imaging-r4/StructureDefinition/DiagnosticReportEuImaging"
    ]
  },
  "language": "de-DE",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition",
      "valueReference": {
        "reference": "Composition/CompositionSemiStructured"
      }
    },
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.note",
      "valueAnnotation": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/annotationType",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://loinc.org",
                  "code": "59776-5",
                  "display": "Findings"
                }
              ]
            }
          }
        ],
        "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/5.0/StructureDefinition/extension-DiagnosticReport.note",
      "valueAnnotation": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/annotationType",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://loinc.org",
                  "code": "59776-5",
                  "display": "Findings"
                }
              ]
            }
          }
        ],
        "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."
      }
    }
  ],
  "identifier": [
    {
      "system": "http://example.org/myhosptital/reportidentifiers",
      "value": "o32u4js8492ff"
    }
  ],
  "basedOn": [
    {
      "type": "ServiceRequest",
      "identifier": {
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
              "code": "ACSN"
            }
          ]
        },
        "system": "http://example.org/myhosptital/accessionsystem",
        "value": "123456789"
      }
    }
  ],
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code": "RAD",
          "display": "Radiology"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "24802-1",
        "display": "MR Knee"
      }
    ]
  },
  "subject": {
    "reference": "Patient/PatientSemiStructuredReport"
  },
  "effectiveDateTime": "2025-05-08",
  "performer": [
    {
      "reference": "Organization/OrganizationSemiStructuredReport"
    }
  ],
  "resultsInterpreter": [
    {
      "reference": "PractitionerRole/PractitionerRoleSemiStructuredReportAuthor"
    }
  ],
  "imagingStudy": [
    {
      "reference": "ImagingStudy/ImagingStudySemiStructuredReport1"
    },
    {
      "reference": "ImagingStudy/ImagingStudySemiStructuredReport2"
    }
  ],
  "conclusion": "Beginnende Großzehengrundgelenksarthrose, links mehr als rechts. Z.n. Umstellungsosteotomie des MFK1 links.",
  "presentedForm": [
    {
      "contentType": "application/pdf",
      "language": "de-DE",
      "url": "./Binary/semi-structured-pdf"
    }
  ]
}