ARCHETYPE ID | openEHR-EHR-OBSERVATION.imaging_exam_result.v1 |
Concept | Imaging examination result |
Description | The result of an imaging examination performed on an individual, using radiological techniques. |
Use | Use 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. |
Misuse | Not 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. |
Purpose | To record the findings on imaging examination of a specified body structure or region and their interpretation, using radiological techniques. |
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. |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2011-02-07 |
Other Details Language | Author 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, |
Keywords | image, radiology, modality, xray, CT, ultrasound, MRI, diagnostic, scan, x-ray, imaging, biomagnetic, densitometry, tomography, radiography, magnetic, resonance, mammography, nuclear, medicine, positron, PET, angiography, fluoroscopy |
Lifecycle | published |
UID | b4a88b6a-33f1-45df-b961-75c3e7eca950 |
Language used | en |
Citeable Identifier | 1013.1.1494 |
Revision Number | 1.1.1 |
All | Archetype [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=
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