ARCHETYPE Imaging examination result (openEHR-EHR-OBSERVATION.imaging_exam_result.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.imaging_exam_result.v0
ConceptImaging examination result
DescriptionRecord the findings and interpretation of an imaging examination performed.
UseUse to record all results related to the diagnostic imaging aspects of any imaging examinations performed. Use to record the imaging examination components (only) of a more complex procedure, including those that may have been undertaken under imaging guidance. More complex procedures (such as echocardiaograms or Bone density scans) may be represented using templates or specialised archetypes where additional report content is appropriate. Will normally be reported back to the requesting clinician as one component within the context of an overall COMPOSITION-based report.
MisuseNot to be used to record non-imaging examination findings or activities. For example when imaging is performed as part of a procedure the information related to the procedure must be recorded using the ACTION.procedure archetype or an OBSERVATION for the operative findings. This archetype will only be used to record the findings from the imaging. Not to be used to record details about any parallel procedure undertaken. Use the specific procedure-related archetypes, for example ACTION.procedure. Not to be used to record details about medications administered during the imaging test. Use specific medication-related archetypes, for example ACTION.medication.
PurposeTo record the findings and interpretation of an imaging examination, or series of examinations, performed.
ReferencesIHE.net Technical Frameworks - Radiology [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.ihe.net/Technical_Framework/index.cfm#radiology

Faculty of Clinical Radiology Council. Clinical Radiology Written Report Guidelines, Version 6.0 [Internet]. Sydney: The Royal Australian and New Zeland College of Radiologists; 2017 Jan [cited 2020 Mar 31]. 10 p. Available from: https://www.ranzcr.com/college/document-library/clinical-radiology-written-report-guidelines

RSNA.org: Radiology Reporting [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.rsna.org/Informatics/radreports.cfm

Radiology Written Report Guideline Project (Draft Consultation); December 2010.

Diagnostic Imaging data specifications; NEHTA, version 1.0, 2007 Jun 29.

Imaging examination result, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. London: NEHTA. Authored: 11 Feb 2007. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.943_6 (no longer available).
Copyright© openEHR Foundation
AuthorsAuthor name: Grahame Grieve
Organisation: Health Intersections Pty Ltd
Email: grahame@healthintersections.com.au
Date originally authored: 2011-02-07
Other Details LanguageAuthor name: Grahame Grieve
Organisation: Health Intersections Pty Ltd
Email: grahame@healthintersections.com.au
Date originally authored: 2011-02-07
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=IHE.net Technical Frameworks - Radiology [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.ihe.net/Technical_Framework/index.cfm#radiology Faculty of Clinical Radiology Council. Clinical Radiology Written Report Guidelines, Version 6.0 [Internet]. Sydney: The Royal Australian and New Zeland College of Radiologists; 2017 Jan [cited 2020 Mar 31]. 10 p. Available from: https://www.ranzcr.com/college/document-library/clinical-radiology-written-report-guidelines RSNA.org: Radiology Reporting [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.rsna.org/Informatics/radreports.cfm Radiology Written Report Guideline Project (Draft Consultation); December 2010. Diagnostic Imaging data specifications; NEHTA, version 1.0, 2007 Jun 29. Imaging examination result, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. London: NEHTA. Authored: 11 Feb 2007. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.943_6 (no longer available)., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=636D8356D589C61CAD7589B340C685AD, build_uid=6c348d26-896c-47ac-a556-7b57ddfd1d4e, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID9ae33444-96c1-4f1c-8724-7a0e4366aebf
Language useden
Citeable Identifier1051.32.237
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Record the findings and interpretation of an imaging examination performed., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Sharmila Biswas, Australia
Eric Browne
David Cartwright, Queensland Health, Australia
Stephen Chu, NEHTA, Australia (Editor)
Matthew Cordell, NEHTA, Australia
Andre de Wolf, NeHTA, Australia
David Evans, Queensland Health, Australia
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia
Grahame Grieve, Health Intersections Pyty Ltd, Australia (Editor)
Mary Kelaher, NEHTA, Australia
Diane Kirkham, NEHTA, Australia
Robert L'egan, NEHTA, Australia
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Mike Martyn, The Hobart Anaesthetic Group, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Michael Osborne, Mater Health Services, Australia
Ning Pan
Chris Pearce, Melbourne East GP Network, Australia
Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia
Cathy Richardson, NEHTA, Australia
Stephen Royce, NEHTA, Australia
Eleanor Royle
Don Stewart
Michael Thompson, Queensland Health, Australia
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia, originalLanguage=en, translators=
  • German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de, Application: Adl Designer
    Notes: Generated automatically by Adl Designer
  • Norwegian Bokmål: Application: Adl Designer
    Notes: Generated automatically by Adl Designer
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={content=[], description=[], details=[], source=[], capabilities=[], other_participations=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique, description=Narrative description about the technical details and procedure., comment=For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0041], code=at0041, itemType=SLOT, level=2, text=Structured technique, description=Additional structured details of technical details and procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0057], code=at0057, itemType=ELEMENT, level=2, text=Imaging quality, description=Narrative description about the quality of the examination., comment=For example: the nature of any limitations and their impact on interpretation., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Receiving imaging service, description=Demographic details about the receiving imaging service performing the imaging test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Requester order identifier, description=The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Examination requested name, description=Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0030], code=at0030, itemType=SLOT, level=3, text=Requester, description=Details about the clinician or organisation requesting the imaging examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=3, text=Report identifier, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=3, text=(Image details), description=Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint:
  • Reported image [Details about the image being reported.]
  • Comparison image [Details about an image being compared to the image being reported.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=4, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=DICOM series identifier, description=Unique identifier of this series allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Position, description=Description of the subject of care's positon when the image was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=4, text=Image DateTime, description=Specific date/time the imaging examination was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], provider=[], activities=[], state=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=4, text=Confounding factors, description=Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], ism_transition=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Test name, description=The name of the imaging examination or procedure performed., comment=Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Modality, description=Type of equipment that originally acquired the image or series of images., comment=Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0055], code=at0055, itemType=ELEMENT, level=4, text=Anatomical site, description=Simple description about the physical place on, or in, the body that was imaged., comment=This data element is redundant if the anatomical site is identified in the 'Test name'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=SLOT, level=4, text=Structured anatomical site, description=Structured detail about the anatomical site related to the entire result., comment=Identification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Overall result status, description=The status of the examination result as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered [No result yet available.]
  • Interim [This is an initial or interim result: data may be missing or verification not been performed.]
  • Final [The result is complete and verified by the responsible radiologist.]
  • Amended [The result has been modified subsequent to being Final, and is complete and verified by the radiologist.]
  • Cancelled / Aborted [The result is not available because the examination was not started or completed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=DateTime result issued, description=The date and/or time that the result was issued for the recorded 'Examination result status'., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Clinical information provided, description=Description of clinical information available at the time of interpretation of results., comment=This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Findings, description=Narrative description of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0044], code=at0044, itemType=SLOT, level=4, text=Imaging findings, description=Structured details about each imaging finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.imaging_finding.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=4, text=Comparison with previous, description=Narrative descripition about the comparison of this image, or series of images, with previous similar examinations., comment=If there is no availability of previous imaging and/or reports this should also be stated using this data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Conclusion, description=Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate., comment=Also referred to as 'Opinion' or 'Impression'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0058], code=at0058, itemType=ELEMENT, level=4, text=Imaging differential diagnosis, description=Single word, phrase or brief description representing a possible condition or diagnosis., comment=This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Imaging diagnosis, description=Single word, phrase or brief description representing the likely condition or diagnosis., comment=This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0045], code=at0045, itemType=SLOT, level=4, text=Image representation, description=Digital image or video representing the exam result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0059], code=at0059, itemType=ELEMENT, level=4, text=Recommendation, description=Suggestion for further imaging, investigations and/or referral, and associated rationale., comment=This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the examination not captured in other fields., comment=For example: a note that the film was given to the patient., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], target=[], identities=[], items=[], relationships=[], credentials=[], context=[], contacts=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0025], code=at0025, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique, description=Narrative description about the technical details and procedure., comment=For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0041], code=at0041, itemType=SLOT, level=2, text=Structured technique, description=Additional structured details of technical details and procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0057], code=at0057, itemType=ELEMENT, level=2, text=Imaging quality, description=Narrative description about the quality of the examination., comment=For example: the nature of any limitations and their impact on interpretation., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Receiving imaging service, description=Demographic details about the receiving imaging service performing the imaging test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Requester order identifier, description=The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Examination requested name, description=Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0030], code=at0030, itemType=SLOT, level=3, text=Requester, description=Details about the clinician or organisation requesting the imaging examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=3, text=Report identifier, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=3, text=(Image details), description=Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint:
  • Reported image [Details about the image being reported.]
  • Comparison image [Details about an image being compared to the image being reported.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=4, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=DICOM series identifier, description=Unique identifier of this series allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Position, description=Description of the subject of care's positon when the image was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=4, text=Image DateTime, description=Specific date/time the imaging examination was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]