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. When imaging is carried out as part of a more complex or operative procedure, use this archetype to record only the imaging examination components. In this situation, it is recommended that all related archetypes - imaging, procedure, measurements, etc - 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 non-imaging examination findings. Not to be used to record structured details about any procedure undertaken. Use the specific procedure-related archetypes, for example ACTION.procedure. Not to be used to record structured 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.
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.

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.

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. 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. 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=782580C6189339D6E702D47D2B58B0B1, build_uid=4533968a-10a8-445d-bb9c-3c23e2e5d6ad, revision=0.0.1-alpha}
Keywordsimage, radiology, modality, xray, CT, ultrasound, MRI
Lifecyclein_development
UID9ae33444-96c1-4f1c-8724-7a0e4366aebf
Language useden
Citeable Identifier1246.145.613
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, Helse Vest IKT AS, 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 Pty Ltd, Australia (Editor)
Mary Kelaher, NEHTA, Australia
Diane Kirkham, NEHTA, Australia
Robert L'egan, NEHTA, Australia
Heather Leslie, Atomica Informatics, 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, 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
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
Swedish: Linda Aulin, Region Stockholm, linda.aulin@sll.se
Norwegian Bokmål: Application: Adl Designer, Notes: Generated automatically by Adl Designer
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={other_participations=[], activities=[], source=[], items=[], identities=[], ism_transition=[], contacts=[], relationships=[], credentials=[], 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]], 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 is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Possible candidate terminologies are 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 'Test 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=Target site, description=Simple description about the body site or region targetted for imaging., comment=If the 'Target site' is specified by a code in the 'Test 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[at0006], code=at0006, itemType=SLOT, level=4, text=Structured target site, description=Structured detail about the anatomical site related to the entire result., comment=If the 'Target site' is specified by a code in the 'Test name', then this field may be redundant. Identification of an 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[at0061], code=at0061, itemType=ELEMENT, level=4, text=Clinical query, description=Narrative description about the reason for requesting the examination., 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[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=This may include a link to the clinical information provided in the original examination request or elsewhere in 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 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=Structured imaging findings, description=Structured details about the imaging findings., 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, 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., 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=Study 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=Study quality description, description=Narrative description about the quality of the examination study., 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=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[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 image or video representing the examination 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.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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], capabilities=[], target=[], provider=[], content=[], details=[], description=[], 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]], context=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Imaging service, description=Demographic 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[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details concerning a single examination requested., comment=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., 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:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v0 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Order identifier, description=The local identifier assigned to the examination order by the order filler, usually by the receiving 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[at0036], code=at0036, itemType=ELEMENT, level=2, text=DICOM study identifier, description=Unique identifier of the reported study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0033], code=at0033, itemType=ELEMENT, level=2, 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[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique, description=Narrative description about the technical aspects of capturing the image/s., comment=Use this data element to provide an outline of technique. 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.' It is particularly useful to record technical limitations or any deviation from normal, such as capturing a non-routine alternative or additional imaging., 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[at0062], code=at0062, itemType=ELEMENT, level=2, text=Procedure, description=Narrative description about the clinical aspects of capturing the image/s., 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. RM attributes allow links to the actual clinical procedure, contrast administration and vital signs records captured within the health record using ACTION.procedure, ACTION.medication, EVALUATION.adverse_reaction_risk and similar archetypes., 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=Reported image/s, description=Details about each image being reported., 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.media_file.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0064], code=at0064, itemType=CLUSTER, level=2, text=Comparison images, description=Details about an image or series being compared to the reported image., 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[at0064]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=DICOM series identifier, description=Unique identifier of the reported 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[at0064]/items[at0067], code=at0067, itemType=SLOT, level=3, text=Comparison image/s, description=Details about each image used for comparison., 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.media_file.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0069], code=at0069, itemType=SLOT, level=2, text=Device, description=, 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[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]]}, 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], 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], 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]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Imaging service, description=Demographic 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[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details concerning a single examination requested., comment=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., 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:
openEHR-EHR-CLUSTER.organisation.v0 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.person.v0 and specialisations or
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Order identifier, description=The local identifier assigned to the examination order by the order filler, usually by the receiving 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[at0036], code=at0036, itemType=ELEMENT, level=2, text=DICOM study identifier, description=Unique identifier of the reported study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0033], code=at0033, itemType=ELEMENT, level=2, 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[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique, description=Narrative description about the technical aspects of capturing the image/s., comment=Use this data element to provide an outline of technique. 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.' It is particularly useful to record technical limitations or any deviation from normal, such as capturing a non-routine alternative or additional imaging., 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[at0062], code=at0062, itemType=ELEMENT, level=2, text=Procedure, description=Narrative description about the clinical aspects of capturing the image/s., 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. RM attributes allow links to the actual clinical procedure, contrast administration and vital signs records captured within the health record using ACTION.procedure, ACTION.medication, EVALUATION.adverse_reaction_risk and similar archetypes., 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=Reported image/s, description=Details about each image being reported., 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.media_file.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0064], code=at0064, itemType=CLUSTER, level=2, text=Comparison images, description=Details about an image or series being compared to the reported image., 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[at0064]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=DICOM series identifier, description=Unique identifier of the reported 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[at0064]/items[at0067], code=at0067, itemType=SLOT, level=3, text=Comparison image/s, description=Details about each image used for comparison., 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.media_file.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0069], code=at0069, itemType=SLOT, level=2, text=Device, description=, 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[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]