TEMPLATE Imaging (Imaging)

TEMPLATE ID	Imaging
Concept	Imaging
Description	Not Specified
Purpose	Not Specified
References
Authors	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2021-12-14
Other Details Language	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2021-12-14
Other Details (Language Independent)	Sem Ver: 10.0.0 MD5-CAM-1.0.1: 1988bb5029406389f2b883ee43f21137 PARENT:MD5-CAM-1.0.1: 7F064FABE9120B9001DA67384AD02B89 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.421
Root archetype id	openEHR-EHR-OBSERVATION.imaging_exam_result.v0
Pelvic ultrasound, early pregnancy	Pelvic ultrasound, early pregnancy: 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 is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Possible candidate terminologies are LOINC, SNOMED CT or RadLex. Pelvic ultrasound
Examination date	Examination date: The date and time or interval of data and time when the imaging examination was carried out. Date/Time Interval of Date/Time
Overall test status	Overall test status: The status of the imaging examination result as a whole. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements. Coded Text Registered Partial Preliminary Final Amended Corrected Appended Cancelled Entered in error Unknown Text
Overall test status timestamp	Overall test status timestamp: The date and/or time that ‘Overall test status’ was assigned.
Imaging findings	Imaging findings: Narrative description of the clinical findings.
Imaging examination of the uterine body	Imaging examination of the uterine body: Findings observed in an imaging examination targeting the uterine body, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Uterine body
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Imaging examination of a single gestational sac	Imaging examination of a single gestational sac: Findings observed in an imaging examination targeting a single gestational sac, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Gestational sac
Anatomical location	Anatomical location: Simple body site for the identified structure. If the anatomical location of the identified body structure is known, this data element is redundant.
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Imaging examination of a fetus in utero	Imaging examination of a fetus in utero: Findings observed in an imaging examination targeting a single embryo or fetus, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Fetus
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Fetal biometry	Fetal biometry: Measurements of an embryo or fetus taken during an antenatal ultrasound examination.
Crown-rump length (CRL)	Crown-rump length (CRL): Measured length of the embryo or fetus from the top of its head to bottom of buttocks. >=0; >=0 Units: mm cm
Biparietal diameter (BPD)	Biparietal diameter (BPD): *
Head circumference (HC)	Head circumference (HC): *
Trans-cerebellar diameter (TCD)	Trans-cerebellar diameter (TCD): *
Occipito-frontal diameter (OFD)	Occipito-frontal diameter (OFD): *
Interocular distance (IOD)	Interocular distance (IOD): *
Binocular distance (BOD)	Binocular distance (BOD): *
Abdominal circumference (AC)	Abdominal circumference (AC): *
Femur length (FL)	Femur length (FL): *
Humeral length (HL)	Humeral length (HL): *
Impression	Impression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure. Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Label	Label: A label for the embryo or fetus. Used to differentiate findings for each embryo or fetus in a multiple pregnancy.
Cardiac activity	Cardiac activity: * Present Absent Indeterminate
Heart rate	Heart rate: The observed heart rate for the embryo or fetus. >=0 /min
Estimated gestational age	Estimated gestational age: Estimated gestational age using radiographic techniques. P0D..P50W Units: Week Day
Estimated weight	Estimated weight: Estimated fetal weight using radiographic techniques. >=0; >=0 Units: g kg
Impression	Impression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure. Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Mean Sac Diameter (MSD)	Mean Sac Diameter (MSD): * Units: mm
Yolk sac presence	Yolk sac presence: The presence or absence of a yolk sac. Present, single Present, multiple Absent Indeterminate
Yolk sac description	Yolk sac description: Narrative description about the yolk sac.
Amnion presence	Amnion presence: The presence or absence of an amnion. Present, single Present, multiple Absent Indeterminate
Amnion description	Amnion description: Narrative description about the amnion.
Impression	Impression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure. Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Length	Length: The length of the uterus. Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the external os of the cervix. >=0; >=0 Units: mm cm
Width	Width: The width of the uterus. Usually measured at the widest dimension in the transverse or coronal plane, perpendicular to the length. >=0; >=0 Units: mm cm
Depth	Depth: The depth or height of the uterus. Usually measured in the sagittal plane, from the anterior to posterior walls, perpendicular to the length. Also known as 'antero-posterior diameter'. >=0; >=0 Units: mm cm
Endometrium description	Endometrium description: Narrative description about the endometrium. For example: thickness, focal abnormalities, echogenicity, and the presence and characteristics of fluid or masses in the cavity. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-abnormality nested within the 'Additional details' SLOT.
Endometrial thickness	Endometrial thickness: Maximal measured thickness of the endometrium. Also known as the endometrial stripe. >=0 mm
Endometrial texture	Endometrial texture: Description about the endometrial texture. For example: homogeneous or heterogeneous; or describing ultrasound echogenicity as hypoechoic, isoechoic, or hyperechoic.
Intrauterine pregnancy	Intrauterine pregnancy: The presence or absence of an intrauterine pregnancy. Present, viable Absent Indeterminate Present, non-viable
Number of gestations	Number of gestations: Number of gestations observed. Count>=0 Coded Text Single Multiple
Chorionicity	Chorionicity: The number of chorionic (outer) membranes or placentas observed in a multiple pregnancy. Count>=0 Coded Text Monochorionic Dichorionic Text
Amnionicity	Amnionicity: The number of amnions (inner membranes) or yolk sacs observed in a multiple pregnancy. Count Text Coded Text Monoamnionic Diamnionic
Myometrium description	Myometrium description: Narrative description about the myometrium. For example: contour changes, texture, masses, and cysts as well as symmetry between the anterior and posterior segments of the myometrium. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-abnormality nested within the 'Additional details' SLOT.
Myometrial walls	Myometrial walls: Description of the relative thickness of the endometrial walls. Text Coded Text Symmetrical Asymmetrical
Myometrial texture	Myometrial texture: Description about the myometrial texture. For example: homogeneous or heterogeneous.
Junctional zone	Junctional zone: Description about the junctional zone of the myometrium. For example: regular, interrupted, or not visible.
Junctional zone thickness	Junctional zone thickness: Measured thickness of the junctional zone. >=0 mm
Uterine axis	Uterine axis: The axis of the cervix relative to the vagina. Also known as 'position'. Anteverted Axial Retroverted
Uterine flexion	Uterine flexion: The axis of the uterine fundus relative to the axis of the cervix. Anteflexed Retroflexed
IUD presence	IUD presence: The presence or absence of an intrauterine contraceptive device. Present Absent Indeterminate
IUD description	IUD description: Narrative description about an observed IUD in the uterus.
Imaging examination of the rectouterine pouch	Imaging examination of the rectouterine pouch: Findings observed in an imaging examination targeting the rectouterine pouch, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Rectouterine pouch
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Imaging examination of an adnexal mass	Imaging examination of an adnexal mass: Findings of a morphological abnormality observed in an imaging examination targeting a mass near the uterus, including the ovaries, fallopian tubes, and connecting tissues, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Morphological abnormality Adnexal mass
Anatomical location	Anatomical location: Simple body site for the identified structure. If the anatomical location of the identified body structure is known, this data element is redundant.
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Impression	Impression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure. Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Label	Label: A label for the abnormality. Use to differentiate one abnormality from another when there is more than one present at the same site.
Type	Type: The type of abnormality. Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 \| Mass (morphologic abnormality) \| hierarchy. Unilocular cyst Unilocular-solid cyst Multilocular cyst Multilocular-solid cyst Solid tumour Indeterminate
Diameter	Diameter: A measured diameter of the abnormality. This data element has 3 occurrences to allow for 3 measurements in different axes. >=0; >=0 Units: mm cm
Shape	Shape: The shape of the abnormality.
Texture	Texture: The texture of the abnormality.
Definition	Definition: The definition of the abnormality. Text Coded Text Well-defined Poorly-defined
Contour	Contour: The contour of the abnormality.
Margin	Margin: The margin of the abnormality.
Calcification	Calcification: Presence of calcification in the abnormality. Present Absent
Effect	Effect: Narrative description about the effect of the abnormality on surrounding structures. For example: 'pressing on blood vessel'.
Vascularisation	Vascularisation: Assessment of the blood flow to the abnormality. Often determined by colour doppler or similar. Text Coded Text None Mild Moderate Marked
Solid diameter	Solid diameter: A measured diameter of the largest solid tissue component. This data element has 3 occurrences to allow for 3 measurements in different axes. >=0; >=0 Units: mm cm
Number of cyst locules	Number of cyst locules: The number of cyst locules in the adnexal mass. >=0
Number of papillary projections	Number of papillary projections: The number of papillary projections in the adnexal mass. >=0
Maximal septum width	Maximal septum width: The measured width of the thickest septum. >=0 mm
Impression	Impression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure. Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Free fluid presence	Free fluid presence: * Present Absent
Amount of free fluid	Amount of free fluid: The amount of fluid observed. Coded Text Small Medium Large Quantity>=0; >=0 Units: l ml
Diameter	Diameter: A measured diameter of the recto-uterine pouch. This data element has 3 occurrences to allow for measurements in 3 different axes. >=0; >=0 Units: mm cm
Comparison	Comparison: Narrative description about the comparison of this examination, with previous similar studies. Also use this data element to indicate if no comparison images and/or reports are available.
Imaging quality	Imaging quality: Assessment about the quality of the examination. 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'.
Imaging quality description	Imaging quality description: Narrative description about the quality of the examination. 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.
Overall impression	Overall impression: Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate. Also referred to as 'Opinion' or 'Conclusion'. Usually equivalent to the FHIR DiagnosticReport.conclusion.
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. 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.
Protocol
Report identifier	Report identifier: The unique identifier designated by the imaging service to the report.
Examination request details	Examination request details: Details concerning a single examination requested. 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.
Receiver order identifier	Receiver order identifier: The local identifier assigned to the imaging examination order by the order filler, usually by the Radiology Information System (RIS). Assigning an identifier to a request by the Radiology lnformation System (RIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier. Identifier Coded Text
Requester order identifier	Requester order identifier: The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier. Identifier Text
Examination requested name	Examination requested name: Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.
Technique	Technique: Name of the technique or technical procedure used to capture the image/s. Coding of the 'Technique' with a terminology is pemitted. Multiple occurrences allow for identification of one or more techniques. If the technique needs to be recorded at study level, use the 'Technique' data element within the CLUSTER.imaging_study_detail archetype.
Technique description	Technique description: Narrative description about the technique or technical procedure used to capture the image/s. Use this data element to provide an outline of technique, including technical limitations or deviation from the normal 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.
Procedure	Procedure: Identification of the clinical procedure or management used as part of capturing the image/s. In implementations, RM links can be created from this data element to relevant ACTION.medication, ACTION.procedure or similar archetypes stored within the health record that document the actual clinical procedures and related activities carried out. If the procedure needs to be recorded at study level, use the 'Procedure' data element within the CLUSTER.imaging_study_details archetype instead.
Procedure description	Procedure description: Narrative description about the clinical procedure or other clinical considerations used to capture the image/s. 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.
Imaging study details	Imaging study details: Details about specific images, including DICOM studies, series or instances.
Study identifier	Study identifier: Unique identifier for the imaging study assigned by the radiology service. Also known in FHIR as ImagingStudy.identifier.
Study status	Study status: The current state of the Study. Also known in FHIR as ImagingStudy.status. Registered Available Cancelled Unknown
Study description	Study description: Institution-generated description or classification of the study (component) performed. Also known in FHIR as ImagingStudy.description and DICOM as 'Study description'.
Modality	Modality: The type of diagnostic equipment, or function or technique of that equipment, that originally acquired, the data used to create the image study. Coding of the 'Modality' with a value set is recommended. For example, the DICOM CID 29 Acquisition Modality value set. This data element has multiple occurrences to allow specification of submodalities such as 'Doppler' as a form of 'Ultrasound'. Also known in FHIR as ImagingStudy.modality.
Study date	Study date: Date and time the study started. Also known in FHIR as ImagingStudy.started.
Study end point	Study end point: Location of where to query for imaging content and metadata (QIDO-RS, WADO-RS, or WADO-URI). The network service providing access (e.g., query, view, or retrieval) for the study. Also known in FHIR as ImagingStudy.endpoint. URI Text
Procedure reason	Procedure reason: *
Imaging series details	Imaging series details: *
Series identifier	Series identifier: Unique identifier for the imaging study assigned by the radiology service. Also known in FHIR as ImagingStudy.identifier.
Series number	Series number: The numeric identifier of this series in the study. Also known in FHIR as ImagingStudy.series.number.
Modality	Modality: The type of diagnostic equipment, or function or technique of that equipment, that originally acquired, the data used to create the image series. Coding of the 'Modality' with a value set is recommended. For example, the DICOM CID 29 Acquisition Modality value set. This data element has multiple occurrences to allow specification of submodalities such as 'Doppler' as a form of 'Ultrasound'. Also known in FHIR as ImagingStudy.series.modality.
Number of instances	Number of instances: The number of instances contained in the series. Also known in FHIR as ImagingStudy.series.numberOfInstances.
Series end point	Series end point: Location of where to query for imaging content and metadata (QIDO-RS, WADO-RS, or WADO-URI). The network service providing access (e.g., query, view, or retrieval) for the series. Also known in FHIR as ImagingStudy.series.endpoint. URI Text
Technique	Technique: * Coding of the 'Technique' with a terminology is recommended. Multiple occurrences allow for identification of one or more techniques. If the technique needs to be recorded at the whole of result level, use the 'Technique' data element within the OBSERVATION.imaging_exam_result archetype instead.
Procedure	Procedure: Identification of the clinical procedure or management used as part of capturing the study. Coding of the 'Procedure ' with a terminology is recommended. In implementations, RM links can be created from this data element to relevant ACTION.medication, ACTION.procedure or similar archetypes stored within the health record that document the actual clinical procedures and related activities carried out. Multiple occurrences allow for identification of one or more techniques. If the procedure needs to be recorded at the whole of result level, use the 'Procedure' data element within the OBSERVATION.imaging_exam_result archetype instead.