FHIRsmith: DiagnosticReport/DiagnosticReport-DiagnosticReportStructured.json

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Package	hl7.fhir.eu.imaging-r4
Resource Type	DiagnosticReport
Id	DiagnosticReport-DiagnosticReportStructured.json
FHIR Version	R4

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Narrative

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

Id:	DiagnosticReportStructured
Code:	Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en) or 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision ( http://www.ama-assn.org/go/cpt: 93351 )
Identifier:	http://example.org/myhosptital/reportidentifiers: dfkjewoieoijwoskdjf
BasedOn:	Identifier: Accession ID/87654321
Status:	final
Category:	Cardiac Ultrasound ( http://terminology.hl7.org/CodeSystem/v2-0074: CUS )
Subject:	3D TEE 2D(official) (no stated gender), DoB: 1976-04-29 ( 00 CARDIAC 2)
Period:	2003-06-01
Performer:	Organization Ultrasound centrum
Results Interpreter:	PractitionerRole Cardiology
Results interpreter:	Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion at rest and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV Observation NM Heart First pass and Wall motion W stress and W radionuclide IV
Conclusion:	This was a normal stress echocardiogram. Nothing wrong with this patient See you next year.
Presented form:	application/pdf @ ./Binary/structured-pdf

Id:

DiagnosticReportStructured

Code:

Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en) or 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision ( http://www.ama-assn.org/go/cpt: 93351 )

Identifier:

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

BasedOn:

Identifier: Accession ID/87654321

Status:

final

Category:

Cardiac Ultrasound ( http://terminology.hl7.org/CodeSystem/v2-0074: CUS )

Subject:

3D TEE 2D(official) (no stated gender), DoB: 1976-04-29 ( 00 CARDIAC 2)

Period:

2003-06-01

Performer:

Organization Ultrasound centrum

Results Interpreter:

PractitionerRole Cardiology

Results interpreter:

Conclusion:

This was a normal stress echocardiogram. Nothing wrong with this patient See you next year.

Presented form:

application/pdf @ ./Binary/structured-pdf

Source1

{
  "resourceType": "DiagnosticReport",
  "id": "DiagnosticReportStructured",
  "meta": {
    "profile": [
      "http://hl7.eu/fhir/imaging-r4/StructureDefinition/DiagnosticReportEuImaging"
    ]
  },
  "language": "en-GB",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.composition",
      "valueReference": {
        "reference": "Composition/CompositionStructured"
      }
    },
    {
      "url": "http://hl7.eu/fhir/imaging-r4/StructureDefinition/HL7IDRPatientHistory",
      "valueReference": {
        "reference": "Observation/WeightObservation"
      }
    },
    {
      "url": "http://hl7.eu/fhir/imaging-r4/StructureDefinition/HL7IDRPatientHistory",
      "valueReference": {
        "reference": "Observation/HeightObservation"
      }
    },
    {
      "url": "http://hl7.eu/fhir/imaging-r4/StructureDefinition/HL7IDRPatientHistory",
      "valueReference": {
        "reference": "Observation/BPObservation"
      }
    },
    {
      "url": "http://hl7.eu/fhir/imaging-r4/StructureDefinition/HL7IDRPatientHistory",
      "valueReference": {
        "reference": "Observation/HRObservation"
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Stress Findings**\nNormal baseline electrocardiogram. There was a maximum 1.5mm ST segment depression. The patient exhibited a hypertensive response with stress."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Right Ventricle**\nThe right ventricle is not well visualized. There is mild right ventricular hypertrophy."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Atria**\nA patent foramen ovale is present and there is low risk for embolism. The left atrium is small."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "Mitral Valve\nThe 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."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Tricuspid Valve**\nThe 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."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Aortic Valve**\nThe 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."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Pulmonic Valve**\nThe 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."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Vessels**\nThe aortic root is not well visualized but is probably normal size. Type B aortic dissection. The pulmonary artery is normal size."
      }
    },
    {
      "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": "Procedure findings Narrative"
                }
              ]
            }
          }
        ],
        "text": "**Pericardium**\nThere is pericardial thickening and/or a small pericardial effusion. Large left pleural effusion."
      }
    },
    {
      "url": "http://hl7.eu/fhir/imaging-r4/StructureDefinition/HL7IDRRecommendation",
      "valueReference": {
        "reference": "ServiceRequest/ComeBackNextYearServiceRequest"
      }
    }
  ],
  "identifier": [
    {
      "system": "http://example.org/myhosptital/reportidentifiers",
      "value": "dfkjewoieoijwoskdjf"
    }
  ],
  "basedOn": [
    {
      "type": "ServiceRequest",
      "identifier": {
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
              "code": "ACSN"
            }
          ]
        },
        "system": "http://example.org/myhosptital/accessionsystem",
        "value": "87654321"
      }
    }
  ],
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code": "CUS",
          "display": "Cardiac Ultrasound"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "system": "http://www.ama-assn.org/go/cpt",
        "code": "93351",
        "display": "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise and pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en), 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, bicycle exercise induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision' (en) or 'Real time transthoracic echocardiography with 2-dimensional (2D) image documentation, includes M-mode recording during rest and cardiovascular stress test using treadmill, pharmacologically induced stress, with interpretation and report, including performance of continuous electrocardiographic monitoring, with physician supervision"
      }
    ]
  },
  "subject": {
    "reference": "Patient/PatientStructuredReport"
  },
  "effectiveDateTime": "2003-06-01",
  "performer": [
    {
      "reference": "Organization/OrganizationStructuredReport"
    }
  ],
  "resultsInterpreter": [
    {
      "reference": "PractitionerRole/PractitionerRoleStructuredReportAuthor"
    }
  ],
  "result": [
    {
      "reference": "Observation/RestWmsi01"
    },
    {
      "reference": "Observation/RestWmsi02"
    },
    {
      "reference": "Observation/RestWmsi03"
    },
    {
      "reference": "Observation/RestWmsi04"
    },
    {
      "reference": "Observation/RestWmsi05"
    },
    {
      "reference": "Observation/RestWmsi06"
    },
    {
      "reference": "Observation/RestWmsi07"
    },
    {
      "reference": "Observation/RestWmsi08"
    },
    {
      "reference": "Observation/RestWmsi09"
    },
    {
      "reference": "Observation/RestWmsi10"
    },
    {
      "reference": "Observation/RestWmsi12"
    },
    {
      "reference": "Observation/RestWmsi13"
    },
    {
      "reference": "Observation/RestWmsi14"
    },
    {
      "reference": "Observation/RestWmsi15"
    },
    {
      "reference": "Observation/RestWmsi16"
    },
    {
      "reference": "Observation/RestWmsi17"
    },
    {
      "reference": "Observation/StressWmsi01"
    },
    {
      "reference": "Observation/StressWmsi02"
    },
    {
      "reference": "Observation/StressWmsi03"
    },
    {
      "reference": "Observation/StressWmsi04"
    },
    {
      "reference": "Observation/StressWmsi05"
    },
    {
      "reference": "Observation/StressWmsi06"
    },
    {
      "reference": "Observation/StressWmsi07"
    },
    {
      "reference": "Observation/StressWmsi08"
    },
    {
      "reference": "Observation/StressWmsi09"
    },
    {
      "reference": "Observation/StressWmsi10"
    },
    {
      "reference": "Observation/StressWmsi12"
    },
    {
      "reference": "Observation/StressWmsi13"
    },
    {
      "reference": "Observation/StressWmsi14"
    },
    {
      "reference": "Observation/StressWmsi15"
    },
    {
      "reference": "Observation/StressWmsi16"
    },
    {
      "reference": "Observation/StressWmsi17"
    }
  ],
  "imagingStudy": [
    {
      "reference": "ImagingStudy/ImagingStudStructuredReport"
    }
  ],
  "media": [
    {
      "comment": "Rest",
      "link": {
        "reference": "Media/StructuredKeyImageRest"
      }
    },
    {
      "comment": "Stress",
      "link": {
        "reference": "Media/StructuredKeyImageStress"
      }
    }
  ],
  "conclusion": "This was a normal stress echocardiogram.\nNothing wrong with this patient\nSee you next year.",
  "presentedForm": [
    {
      "contentType": "application/pdf",
      "language": "de-DE",
      "url": "./Binary/structured-pdf"
    }
  ]
}

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