FHIR IG analytics

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Narrative

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

Source1

{
  "resourceType": "Composition",
  "id": "composition-prostate-mpmri-report-example",
  "meta": {
    "profile": [
      "https://hl7.lt/fhir/base/StructureDefinition/imaging-composition-lt"
    ]
  },
  "language": "en",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.eu/fhir/imaging-r5/StructureDefinition/im-composition-diagnosticReportReference",
      "valueReference": {
        "reference": "DiagnosticReport/diagnosticReport-prostate-mpmri-report-example"
      }
    }
  ],
  "identifier": [
    {
      "system": "https://hl7.lt/fhir/prostate/composition-id",
      "value": "mpmri-report-example2-0001"
    }
  ],
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://hl7.eu/fhir/imaging-r5/CodeSystem/Hl7EuDocumentTypes",
        "code": "imaging-report-v0-0-1",
        "display": "Imaging Report V0.0.1"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "18748-4",
          "display": "Diagnostic imaging study"
        }
      ]
    }
  ],
  "subject": [
    {
      "reference": "Patient/patient-male-example"
    }
  ],
  "date": "2024-05-27T10:30:00Z",
  "author": [
    {
      "reference": "PractitionerRole/practitioner-role-radiologist-example"
    }
  ],
  "title": "Multiparametric prostate MRI report",
  "event": [
    {
      "detail": [
        {
          "concept": {
            "coding": [
              {
                "system": "http://dicom.nema.org/resources/ontology/DCM",
                "code": "MR",
                "display": "Magnetic Resonance"
              }
            ]
          },
          "reference": {
            "reference": "ImagingStudy/imagingstudy-prostate-mpmri-example"
          }
        }
      ]
    },
    {
      "detail": [
        {
          "concept": {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "103693007",
                "display": "Diagnostic procedure (procedure)"
              }
            ]
          },
          "reference": {
            "reference": "Procedure/procedure-prostate-mpmri-example"
          }
        }
      ]
    }
  ],
  "section": [
    {
      "title": "Imaging Study",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "18726-0"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Multiparametric prostate MRI performed. PI-RADS 5 anterior transition zone lesion (~32 mm). PRECISE 3 stable disease.</div>"
      },
      "entry": [
        {
          "reference": "ImagingStudy/imagingstudy-prostate-mpmri-example"
        }
      ]
    },
    {
      "title": "Order",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "55115-0",
            "display": "Requested imaging studies information Document"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Order information not specified.</p></div>"
      },
      "emptyReason": {
        "coding": [
          {
            "system": "http://hl7.eu/fhir/imaging-r5/ValueSet/ImSectionEmptyReason",
            "code": "unknown",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "title": "History",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11329-0",
            "display": "History general Narrative - Reported"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Clinical history not documented.</p></div>"
      },
      "emptyReason": {
        "coding": [
          {
            "system": "http://hl7.eu/fhir/imaging-r5/ValueSet/ImSectionEmptyReason",
            "code": "unknown",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "title": "Procedure",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "55111-9",
            "display": "Current imaging procedure descriptions Document"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Procedure details not included.</p></div>"
      },
      "emptyReason": {
        "coding": [
          {
            "system": "http://hl7.eu/fhir/imaging-r5/ValueSet/ImSectionEmptyReason",
            "code": "unknown",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "title": "Comparison",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "18834-2",
            "display": "Radiology Comparison study (narrative)"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No prior studies available.</p></div>"
      },
      "emptyReason": {
        "coding": [
          {
            "system": "http://hl7.eu/fhir/imaging-r5/ValueSet/ImSectionEmptyReason",
            "code": "unknown",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "title": "Findings",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "59776-5",
            "display": "Findings"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Anterior transition zone lesion with PI-RADS 5. No seminal vesicle or neurovascular bundle invasion. Possible capsular contact anteriorly.</div>"
      },
      "entry": [
        {
          "reference": "Observation/imfinding-prostate-lesion1-example"
        }
      ]
    },
    {
      "title": "Impression",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "19005-8",
            "display": "Radiology Imaging study [Impression] (narrative)"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">PI-RADS 5 lesion in the anterior transition zone (~32 mm), extending across midline. PRECISE 3 stable disease. Imaging features consistent with high-suspicion malignancy.</div>"
      },
      "entry": [
        {
          "reference": "Observation/imfinding-prostate-lesion1-example"
        }
      ]
    },
    {
      "title": "Recommendation",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "18783-1",
            "display": "Radiology Study recommendation (narrative)"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Recommendations pending clinical review.</p></div>"
      },
      "emptyReason": {
        "coding": [
          {
            "system": "http://hl7.eu/fhir/imaging-r5/ValueSet/ImSectionEmptyReason",
            "code": "unknown",
            "display": "Unknown"
          }
        ]
      }
    }
  ]
}