| TEMPLATE ID | Myokarditis_MRT |
|---|---|
| Concept | Myokarditis_MRT |
| Description | To be used to report on MRT images for Myokarditis cases. |
| Misuse | Not to be used for X-Ray, MI |
| Purpose | To be used to report on MRT images for Myokarditis cases. |
| References | |
| Authors | name: Mhd Samer Alkarkoukly; organisation: University Hospital Cologne; email: mabbouda@uni-koeln.de; date: 2021-07-06 |
| Other Details Language | name: Mhd Samer Alkarkoukly; organisation: University Hospital Cologne; email: mabbouda@uni-koeln.de; date: 2021-07-06 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1246.169.1866 |
| Root archetype id | openEHR-EHR-COMPOSITION.report-result.v1 |
| Myokarditis_MRT | Myokarditis_MRT: Document to communicate information to others about the result of a test or assessment. |
| Other Context | |
| Report ID | Report ID: Identification information about the report. |
| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
| Imaging examination result | Imaging examination result: Record the findings and interpretation of an imaging examination performed. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test name | Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. |
| Modality | Modality: Type of equipment that originally acquired the image or series of images. Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant. |
| Anatomical site | Anatomical site: Simple description about the physical place on, or in, the body that was imaged. This data element is redundant if the anatomical site is identified in the 'Test name'. |
| Overall result status | Overall result status: The status of the examination result as a whole.
|
| DateTime result issued | DateTime result issued: The date and/or time that the result was issued for the recorded 'Examination result status'. |
| Clinical information provided | Clinical information provided: Description of clinical information available at the time of interpretation of results. This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element. |
| Findings | Findings: Narrative description of the clinical findings. |
| Comparison with previous | Comparison with previous: Narrative descripition about the comparison of this image, or series of images, with previous similar examinations. If there is no availability of previous imaging and/or reports this should also be stated using this data element. |
| Conclusion | Conclusion: Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate. Also referred to as 'Opinion' or 'Impression'. |
| Imaging differential diagnosis | Imaging differential diagnosis: Single word, phrase or brief description representing a possible condition or diagnosis. 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. |
| Imaging diagnosis | Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. 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. |
| Recommendation | Recommendation: Suggestion for further imaging, investigations and/or referral, and associated rationale. This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request. |
| Comment | Comment: Additional narrative about the examination not captured in other fields. For example: a note that the film was given to the patient. |
| State | |
| Confounding factors | Confounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result. |
| Any event (2) | Any event (2): Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test name | Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Default value: MRT für Myokarditis |
| Imaging result | Imaging result: Imaging result as a single value or as a nested group result. |
| Imaging finding | Imaging finding: A single finding in an imaging examination. |
| Finding name | Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
|
| Comment | Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}] |
| Imaging diagnosis | Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. 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. |
| State | |
| Confounding factors | Confounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result. |
| Protocol | |
| Technique | Technique: Narrative description about the technical details and procedure. For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media. |
| Imaging quality | Imaging quality: Narrative description about the quality of the examination. For example: the nature of any limitations and their impact on interpretation. |
| Examination request details | Examination request details: Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype. |
| Requester order identifier | Requester order identifier: The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier. |
| Examination requested name | Examination requested name: Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed. |
| Receiver order identifier | Receiver order identifier: The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number. |
| DICOM study identifier | DICOM study identifier: Unique identifier of this study allocated by the imaging service. |
| Report identifier | Report identifier: The local identifier given to the imaging examination report. |
| (Image details) | (Image details): Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images. |
| Image identifier | Image identifier: Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID). |
| DICOM series identifier | DICOM series identifier: Unique identifier of this series allocated by the imaging service. |
| View | View: The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible. |
| Position | Position: Description of the subject of care's positon when the image was performed. |
| Image DateTime | Image DateTime: Specific date/time the imaging examination was performed. |
| Image | Image: An attached or referenced image of a current view. |