ARCHETYPE Imaging examination result (openEHR-EHR-OBSERVATION.imaging_exam_result.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.imaging_exam_result.v1
ConceptImaging examination result
DescriptionThe result of an imaging examination performed on an individual, using radiological techniques.
UseUse to record the findings on imaging examination of a specified body structure or region and their interpretation, using radiological techniques. This archetype has been designed to focus on the reporting of findings and interpretation associated with a single imaging examination (equivalent to a single DICOM study). References to DICOM-related attributes are included but the focus is on the representation of a clinical report from an imaging examination and not on representing DICOM-related attributes that might be expected within a radiology information system. Specific details about the DICOM series can be recorded using the CLUSTER.imaging_series nested within the 'Series details' SLOT. Detailed findings observed during an imaging examination and targeting a specified structure or region can be recorded by nesting the CLUSTER.imaging_exam and/or its family of specialised archetypes within the 'Structured imaging findings' SLOT in this archetype. It is intended that over time the specific detail in each specialisation will grow to include findings using all imaging modalities. If an imaging examination is carried out as part of a more complex activity, such as a surgical operation carried out under imaging guidance, the imaging findings should be recorded using this archetype. Structured details about the surgical procedure and medications or contrast administered should be recorded using the ACTION.procedure and/or ACTION.medication archetypes, respectively. In this situation, it is recommended that all related archetypes should be reported within the same template. This result 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 findings on physical examination. Use the CLUSTER.exam and/or its family of specialised archetypes for this purpose. Not to be used to replicate the functionality or specifications of a radiology information or source system. Not to be used to record structured details about any procedure undertaken. Use the specific procedure-related archetypes, such as ACTION.procedure archetype for this purpose. Not to be used to record structured details about medications administered during the imaging test. Use specific medication-related archetypes, such as the ACTION.medication archetype for this purpose. Not to be used to record photographs or videos within the health record. Use the CLUSTER.media_file archetype for this purpose.
PurposeTo record the findings on imaging examination of a specified body structure or region and their interpretation, using radiological techniques.
ReferencesClinical Radiology Written Report Guidelines, Version 7.0 [Internet]. Sydney: The Royal Australian and New Zealand College of Radiologists; 2020 Nov 23 [cited 2021 Aug 04]. 10 p. Available from: https://www.ranzcr.com/college/document-library/clinical-radiology-written-report-guidelines.

Digital imaging and Communications in Medicine (DICOM) [Internet]. Medical Imaging Technology Association (MITA); [cited 2022 Jan 25]. Available from: https://www.dicomstandard.org/current.

HL7 FHIR Resource - DiagnosticReport v4.0.1 R4 [Internet]. Health Level Seven International; [accessed 2021 Aug 04]. Available from: https://www.hl7.org/fhir/diagnosticreport.html.

HL7 FHIR Resource - ImagingStudy v4.0.1 R4 [Internet]. Health Level Seven International; [accessed 2021 Aug 04]. Available from: http://hl7.org/fhir/imagingstudy.html.

Larson DB. Strategies for Implementing a Standardized Structured Radiology Reporting Program. Radiographics. 2018 Oct;38(6):1705-1716. doi: 10.1148/rg.2018180040. PMID: 30303804. Available from: https://pubs.rsna.org/doi/10.1148/rg.2018180040.

RSNA.org: RadReport Template Library [Internet]. Radiological Society of North America; [cited 2021 Aug 04]. Available from: https://radreport.org/.

RSNA.org: Proposed Standard Radiology Report Headings. Radiological Society of North America; 2011 Jan 12 [cited 2021 Aug 04]. Available from: http://reportingwiki.rsna.org/index.php/Proposed_Standard_Radiology_Report_Headings.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2011-02-07
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2011-02-07
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Clinical Radiology Written Report Guidelines, Version 7.0 [Internet]. Sydney: The Royal Australian and New Zealand College of Radiologists; 2020 Nov 23 [cited 2021 Aug 04]. 10 p. Available from: https://www.ranzcr.com/college/document-library/clinical-radiology-written-report-guidelines. Digital imaging and Communications in Medicine (DICOM) [Internet]. Medical Imaging Technology Association (MITA); [cited 2022 Jan 25]. Available from: https://www.dicomstandard.org/current. HL7 FHIR Resource - DiagnosticReport v4.0.1 R4 [Internet]. Health Level Seven International; [accessed 2021 Aug 04]. Available from: https://www.hl7.org/fhir/diagnosticreport.html. HL7 FHIR Resource - ImagingStudy v4.0.1 R4 [Internet]. Health Level Seven International; [accessed 2021 Aug 04]. Available from: http://hl7.org/fhir/imagingstudy.html. Larson DB. Strategies for Implementing a Standardized Structured Radiology Reporting Program. Radiographics. 2018 Oct;38(6):1705-1716. doi: 10.1148/rg.2018180040. PMID: 30303804. Available from: https://pubs.rsna.org/doi/10.1148/rg.2018180040. RSNA.org: RadReport Template Library [Internet]. Radiological Society of North America; [cited 2021 Aug 04]. Available from: https://radreport.org/. RSNA.org: Proposed Standard Radiology Report Headings. Radiological Society of North America; 2011 Jan 12 [cited 2021 Aug 04]. Available from: http://reportingwiki.rsna.org/index.php/Proposed_Standard_Radiology_Report_Headings., current_contact=Heather Leslie, , original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=60DD7069B50AAF5B394E3F246F80BCB5, build_uid=7a6046b4-804f-4b4f-bda2-661f5814f290, revision=1.1.1}
Keywordsimage, radiology, modality, xray, CT, ultrasound, MRI, diagnostic, scan, x-ray, imaging, biomagnetic, densitometry, tomography, radiography, magnetic, resonance, mammography, nuclear, medicine, positron, PET, angiography, fluoroscopy
Lifecyclepublished
UIDb4a88b6a-33f1-45df-b961-75c3e7eca950
Language useden
Citeable Identifier1246.145.613
Revision Number1.1.1
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The result of an imaging examination performed on an individual, using radiological techniques., archetypeConceptComment=null, otherContributors=Andreas Abildgaard, OUS, Norway
Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Sharmila Biswas, Australia
Randi Brendberg, Helse Nord RHF, Norway
Eric Browne
David Cartwright, Queensland Health, Australia
Stephen Chu, NEHTA, Australia (Editor)
Matthew Cordell, NEHTA, Australia
Andre de Wolf, NeHTA, Australia
Gunn Elin Blakkisrud, DIPS ASA, Norway
David Evans, Queensland Health, Australia
Peter Fedorcsak, University of Oslo, Norway (openEHR Editor)
Kåre Flø, DIPS ASA, Norway
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia
Heather Grain, Llewelyn Grain Informatics, Australia
Grahame Grieve, Health Intersections Pty Ltd, Australia (Editor)
Roar Holm, Helse Vest IKT A/S, Norway
Kija Indrearne, Helse Bergen, Norway
Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør)
Aud Jorunn Mjelstad, Helse Bergen, Norway
Mary Kelaher, NEHTA, Australia
Diane Kirkham, NEHTA, Australia
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Robert L'egan, NEHTA, Australia
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Luis Marco Ruiz, NST, Spain
Mike Martyn, The Hobart Anaesthetic Group, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Arunakiry Natarajan, medondo, Germany
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, Norway
Michael Osborne, Mater Health Services, Australia
Ning Pan, NEHTA, Australia
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, NEHTA, Australia
Don Stewart, NEHTA, Australia
Natalia Strauch, Medizinische Hochschule Hannover, Germany
Norwegian Review Summary, Norwegian Public Hospitals, Norway
Michael Thompson, Queensland Health, Australia
Olav Thorsen, Stavanger University Hospital, Norway
Gordon Tomes, Australian Institute of Health and Welfare, Australia
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)
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
Swedish: Linda Aulin, Region Stockholm, linda.aulin@sll.se
Norwegian Bokmål: Vebjørn Arntzen, Liv Laugen, ​Oslo University Hospital, Norway, varntzen@ous-hf.no, liv.laugen@ous-hf.no
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], capabilities=[], contacts=[], items=[], credentials=[], content=[], provider=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Study name, description=The name of the imaging examination performed., comment=For example: 'CT abdomen'; 'Doppler ultrasound of renal artery' or 'Plain chest xray'. Coding with a terminology is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Examples of candidate terminologies are the LOINC Imaging Document Codes, RadLex Playbook or SNOMED-CT. Equivalent to DiagnosticReport.code in FHIR., 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[at0091], code=at0091, itemType=ELEMENT, level=4, text=Modality, description=The type of imaging device, process or method that originally acquired or produced the data used to create the images in the study., comment=For example: 'XRay', 'CT scan', 'ultrasound', 'MRI', 'bone densitometry', 'tomography', 'mammography', 'nuclear medicine', 'PET', 'angiography', and 'fluoroscopy'. This data element may be redundant if the modality is clearly represented in the 'Study name'. Alternatively it may also be possible to autopopulate the 'Modality' from a coded 'Study name'. Coding of the 'Modality' with a value set is recommended, such as the DICOM CID 29 Acquisition Modality value set. Equivalent to ImagingStudy.modality in FHIR and Modality (0008, 0060) in DICOM., 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[at0055], code=at0055, itemType=ELEMENT, level=4, text=Target body site, description=Description of the simple body site or region targetted for imaging., comment=If the body site is specified within the text or code for 'Study name', then this field may be redundant. Coding of 'Target body site' with a terminology, such as SNOMED CT, is desirable. Equivalent to ImagingStudy.series.bodySite in FHIR., 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 target body site, description=Structured detail about the body site or region targetted for imaging., comment=If the body site is specified within the text or code for 'Study name', then this field may be redundant., 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[at0070], code=at0070, itemType=ELEMENT, level=4, text=Study date, description=Date/time when the imaging started., comment=Equivalent to ImagingStudy.started in FHIR., 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[at0072], code=at0072, itemType=ELEMENT, level=4, text=Overall result status, description=The status of the imaging examination result as a whole., comment=The values have been aligned with the FHIR Diagnostic report status, with the exception of 'Entered in error' which is relevant only to a messaging-oriented paradigm. Other local codes/terms can be used via the Text 'choice'. In most use cases, only one status is applicable at any time, however this data element allows multiple occurrences for the use cases where there are a variety of types of status that need to be specified, usually within a template. Equivalent to DiagnosticReport.status in FHIR. , uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Registered [The existence of the study is registered, but no result is yet available.]
    • Partial [This is a partial (e.g. initial, interim or preliminary) result but data may be incomplete or unverified.]
    • Preliminary [Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.]
    • Final [The result is complete and verified by an authorised person.]
    • Amended [Subsequent to being final, the result has been modified.]
    • Corrected [Subsequent to being final, the result has been modified to correct an error. This is a sub-category of 'Amended'.]
    • Appended [Subsequent to being final, the result has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.]
    • Cancelled [The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').]
    • Unknown [The status of the result is not known.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0071], code=at0071, itemType=ELEMENT, level=4, text=Status timestamp, description=The date and/or time that ‘Overall result status’ was assigned., 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[at0061], code=at0061, itemType=ELEMENT, level=4, text=Clinical indication, description=Narrative description about the reason the examination was originally requested., comment=Also known as 'Clinical question' or 'Clinical query'., 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[at0014], code=at0014, itemType=ELEMENT, level=4, text=Clinical summary, description=Narrative description of relevant clinical history that provides context for the examination and interpretation of results., comment=Alternatively this data element can include an RM link to clinical information provided in the original examination request or located elsewhere within the health record., 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=Imaging findings, description=Narrative description or overview of all 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=Structured imaging findings, description=Structured details about the imaging examination findings targeting a specific structure or region., 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_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=4, text=Comparison findings, description=Narrative description about the comparison of this examination with previous similar studies., comment=Also use this data element to indicate if no comparison images and/or reports are available. Details about the images used for comparison can be recorded using the 'Comparison study details' CLUSTER, within Protocol., 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[at0063], code=at0063, itemType=ELEMENT, level=4, text=Imaging quality, description=Assessment about the quality of the examination., comment=Coding of the imaging quality with a value set is recommended. For example: 'excellent, good, fair, poor, and non-diagnostic'; or 'adequate, suboptimal and inadequate'. , 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[at0057], code=at0057, itemType=ELEMENT, level=4, text=Imaging quality description, description=Narrative description about the quality of the examination., comment=For example: the nature of any limitations and their impact on interpretation; recommendation that the examination should be repeated; or whether an alternative method of assessment might be more appropriate., 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=Overall impression, 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 'Conclusion'. Equivalent to DiagnosticReport.conclusion in FHIR., 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 diagnosis. Coding with a terminology such as SNOMED CT is preferred, where possible. This data element should be considered as mutually exclusive to "Imaging diagnosis", ie only either "Imaging diagnosis" or "Imaging differential diagnosis" in each instance of the archetype "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 differential diagnosis. Coding with a terminology such as SNOMED CT is preferred, where possible. This data element should be considered as mutually exclusive to "Imaging differential diagnosis", ie only either "Imaging diagnosis" or "Imaging differential diagnosis" in each instance of the archetype "Imaging examination result." Equivalent to DiagnosticReport.conclusionCode in FHIR., 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[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. 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[at0045], code=at0045, itemType=SLOT, level=4, text=Report representation, description=Digital representation of the examination result., comment=Multiple formats are allowed but they should represent equivalent clinical content. For example a pdf version of the report. Equivalent to DiagnosticReport.presentedForm in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.media_file.v1 and specialisations, 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. Equivalent to DiagnosticReport.note in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], relationships=[], context=[], other_participations=[], description=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0092], code=at0092, itemType=ELEMENT, level=2, text=Study instance identifier, description=Unique identifier for the imaging study assigned by the imaging device., comment=Equivalent to Study Instance UID (0020,000D) in DICOM and ImagingStudy.identifier in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0105], code=at0105, itemType=ELEMENT, level=2, text=Study description, description=Radiology service-generated description or classification of the study., comment=Equivalent to ImagingStudy.description in FHIR and Study description (0008, 1030) in DICOM. Possible DICOM examples: MR BREAS, UNIT; NEURO^HEAD; or MR BREASTUNI UE., 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[at0104], code=at0104, itemType=ELEMENT, level=2, text=Report identifier, description=Unique identifier for the imaging report assigned by the radiology service., comment=As one instance of this archetype is used per study, this identifier can be used to connect more than one imaging study within a single combined report. Equivalent to DiagnosticReport.identifier in FHIR. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0099], code=at0099, itemType=ELEMENT, level=2, text=Study status, description=The current state of the imaging study., comment=Equivalent to ImagingStudy.status in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Registered [The existence of the imaging study is registered, but there is nothing yet available.]
    • Available [At least one instance has been associated with this imaging study.]
    • Cancelled [The imaging study is unavailable because the study was not started or not completed.]
    • Unknown [The status is not known by the radiology source system.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0098], code=at0098, itemType=ELEMENT, level=2, text=Study end point, description=Digital location of the imaging content and metadata., comment=This location identifies the network service providing access (for storage, viewing, querying, or retrieval) for the study. Equivalent to ImagingStudy.endpoint in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0106], code=at0106, itemType=ELEMENT, level=2, text=Image details, description=Link to full details of any imaging carried out during the study., comment=Typically referencing images used the DICOM enabled modalities, but this data field provides an alternative method to access the images. Equivalent to DiagnosticReport.imagingStudy in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Imaging service, description=Details about the service, organisation or individual carrying out 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:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0087], code=at0087, itemType=ELEMENT, level=2, text=Technique, description=Name of the radiological procedure used to capture the study., comment=Coding of the 'Technique' with a terminology is permitted. Multiple occurrences allow for identification of one or more techniques., 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[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique summary, description=Narrative description about the radiological procedure used to capture the study., comment=Use this data element to describe a summary of technique, including technical limitations or deviation from the normal technical procedures. For example: '5 mm axial images from the lung bases through the pubic symphysis were acquired following the administration of intravenous and oral contrast. Coronal and Sagittal reformatted images were constructed from the source data.', 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[at0088], code=at0088, itemType=ELEMENT, level=2, text=Procedure, description=Identification of the clinical procedure or management used to capture the study., 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[at0062], code=at0062, itemType=ELEMENT, level=2, text=Procedure summary, description=Narrative description about the clinical procedure or other clinical considerations used to capture the study., comment=Use this data element to describe a summary of the clinical procedure, patient positioning, interventions such as Valsalva manoeuvre, and administration of contrast agent, radiopharmaceuticals and/or treatments as part of the imaging study. For example: '80 ml of Isovue-370 was administered intravenously using a bolus-tracking technique centered on the main pulmonary artery'. It can also be used to record an overview of any issues, complications or adverse reactions encountered. , 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/procedure, description=Additional structured details of technical and clinical aspects of capturing the image/s., 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[at0065], code=at0065, itemType=SLOT, level=2, text=Series details, description=Details about a series included in this report., 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_series.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_series.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0069], code=at0069, itemType=SLOT, level=2, text=Device, description=Details about imaging device/s used to capture the study., 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.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093], code=at0093, itemType=CLUSTER, level=2, text=Comparison study details, description=Details about images from a prior study used for comparison to the reported study., 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[at0093]/items[at0094], code=at0094, itemType=ELEMENT, level=3, text=Study name, description=The name of the comparison imaging examination 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[at0093]/items[at0095], code=at0095, itemType=ELEMENT, level=3, text=Study identifier, description=Unique identifier for the comparison imaging study., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093]/items[at0096], code=at0096, itemType=ELEMENT, level=3, text=Study date, description=Date and time the comparison examination started., 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[at0093]/items[at0097], code=at0097, itemType=ELEMENT, level=3, text=Study end point, description=Digital location of the comparison imaging content and metadata., comment=This location identifies the network service providing access (for storage, viewing, querying, or retrieval) for the study. Equivalent to ImagingStudy.endpoint in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093]/items[at0067], code=at0067, itemType=SLOT, level=3, text=Comparison series details, description=Details about an imaging series being compared to the reported study., 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_series.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_series.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details about a single imaging examination requested., 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[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=Unique identifier for the imaging examination order assigned by the radiology service., comment=Equivalent to the HL7 Filler Order Identifier or DICOM Accession number attribute (0008,0050)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Coded Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Requester order identifier, description=Unique identifier for the imaging examination order assigned by the requester., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, 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 requested., comment=This can be useful in situations where the examination requested differs from the examination performed., 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 and/or organisation requesting the imaging examination., comment=Equivalent to DICOM Referring Physician's Name (0008,0090), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0083], code=at0083, itemType=SLOT, level=2, text=Distribution list, description=Details of additional clinicians or organisations who require a copy of the examination result., comment=The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, 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]], 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]], 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0047]/items[at0108], code=at0108, itemType=ELEMENT, level=4, text=Position, description=Position of the individual during the imaging examination., comment=For example: standing or lying., 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]/state[at0047]/items[at0107], code=at0107, itemType=SLOT, level=4, text=Stabilising appliance, description=Identification of a stabilising appliance in use., comment=For example: braces, casts, external fixation., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null]], ism_transition=[], identities=[], details=[], target=[]}, topLevelItems={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], 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]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0092], code=at0092, itemType=ELEMENT, level=2, text=Study instance identifier, description=Unique identifier for the imaging study assigned by the imaging device., comment=Equivalent to Study Instance UID (0020,000D) in DICOM and ImagingStudy.identifier in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0105], code=at0105, itemType=ELEMENT, level=2, text=Study description, description=Radiology service-generated description or classification of the study., comment=Equivalent to ImagingStudy.description in FHIR and Study description (0008, 1030) in DICOM. Possible DICOM examples: MR BREAS, UNIT; NEURO^HEAD; or MR BREASTUNI UE., 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[at0104], code=at0104, itemType=ELEMENT, level=2, text=Report identifier, description=Unique identifier for the imaging report assigned by the radiology service., comment=As one instance of this archetype is used per study, this identifier can be used to connect more than one imaging study within a single combined report. Equivalent to DiagnosticReport.identifier in FHIR. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0099], code=at0099, itemType=ELEMENT, level=2, text=Study status, description=The current state of the imaging study., comment=Equivalent to ImagingStudy.status in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Registered [The existence of the imaging study is registered, but there is nothing yet available.]
    • Available [At least one instance has been associated with this imaging study.]
    • Cancelled [The imaging study is unavailable because the study was not started or not completed.]
    • Unknown [The status is not known by the radiology source system.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0098], code=at0098, itemType=ELEMENT, level=2, text=Study end point, description=Digital location of the imaging content and metadata., comment=This location identifies the network service providing access (for storage, viewing, querying, or retrieval) for the study. Equivalent to ImagingStudy.endpoint in FHIR., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0106], code=at0106, itemType=ELEMENT, level=2, text=Image details, description=Link to full details of any imaging carried out during the study., comment=Typically referencing images used the DICOM enabled modalities, but this data field provides an alternative method to access the images. Equivalent to DiagnosticReport.imagingStudy in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Imaging service, description=Details about the service, organisation or individual carrying out 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:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0087], code=at0087, itemType=ELEMENT, level=2, text=Technique, description=Name of the radiological procedure used to capture the study., comment=Coding of the 'Technique' with a terminology is permitted. Multiple occurrences allow for identification of one or more techniques., 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[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique summary, description=Narrative description about the radiological procedure used to capture the study., comment=Use this data element to describe a summary of technique, including technical limitations or deviation from the normal technical procedures. For example: '5 mm axial images from the lung bases through the pubic symphysis were acquired following the administration of intravenous and oral contrast. Coronal and Sagittal reformatted images were constructed from the source data.', 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[at0088], code=at0088, itemType=ELEMENT, level=2, text=Procedure, description=Identification of the clinical procedure or management used to capture the study., 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[at0062], code=at0062, itemType=ELEMENT, level=2, text=Procedure summary, description=Narrative description about the clinical procedure or other clinical considerations used to capture the study., comment=Use this data element to describe a summary of the clinical procedure, patient positioning, interventions such as Valsalva manoeuvre, and administration of contrast agent, radiopharmaceuticals and/or treatments as part of the imaging study. For example: '80 ml of Isovue-370 was administered intravenously using a bolus-tracking technique centered on the main pulmonary artery'. It can also be used to record an overview of any issues, complications or adverse reactions encountered. , 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/procedure, description=Additional structured details of technical and clinical aspects of capturing the image/s., 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[at0065], code=at0065, itemType=SLOT, level=2, text=Series details, description=Details about a series included in this report., 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_series.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_series.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0069], code=at0069, itemType=SLOT, level=2, text=Device, description=Details about imaging device/s used to capture the study., 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.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093], code=at0093, itemType=CLUSTER, level=2, text=Comparison study details, description=Details about images from a prior study used for comparison to the reported study., 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[at0093]/items[at0094], code=at0094, itemType=ELEMENT, level=3, text=Study name, description=The name of the comparison imaging examination 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[at0093]/items[at0095], code=at0095, itemType=ELEMENT, level=3, text=Study identifier, description=Unique identifier for the comparison imaging study., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093]/items[at0096], code=at0096, itemType=ELEMENT, level=3, text=Study date, description=Date and time the comparison examination started., 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[at0093]/items[at0097], code=at0097, itemType=ELEMENT, level=3, text=Study end point, description=Digital location of the comparison imaging content and metadata., comment=This location identifies the network service providing access (for storage, viewing, querying, or retrieval) for the study. Equivalent to ImagingStudy.endpoint in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0093]/items[at0067], code=at0067, itemType=SLOT, level=3, text=Comparison series details, description=Details about an imaging series being compared to the reported study., 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_series.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_series.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details about a single imaging examination requested., 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[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=Unique identifier for the imaging examination order assigned by the radiology service., comment=Equivalent to the HL7 Filler Order Identifier or DICOM Accession number attribute (0008,0050)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Coded Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Requester order identifier, description=Unique identifier for the imaging examination order assigned by the requester., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  Text
, 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 requested., comment=This can be useful in situations where the examination requested differs from the examination performed., 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 and/or organisation requesting the imaging examination., comment=Equivalent to DICOM Referring Physician's Name (0008,0090), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0083], code=at0083, itemType=SLOT, level=2, text=Distribution list, description=Details of additional clinicians or organisations who require a copy of the examination result., comment=The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, 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]