Imaging
Class ImageInterpretationReport

Represents the radiology/nuclear medicine report as known by the originating system.

Attributes
String additionalClinicalHistory additionalClinicalHistory

Contain a patient's clinical history as well as instructions to the interpreting physician. For example, the instructions might be for the physician to interpret the exam images to rule out the possibility of the patient having a certain disease. The 'additional clinical history' is written by the interpreting physician and is entered into the system by the transcriptionist. Voice Recognition systems allow the interpreting physician to directly enter this information into the 'additional clinical history' field.

«TS» PointInTime dateEntered dateEntered

The date and time that the report was entered into the system by the transcriptionist.

«TS» PointInTime dateReported dateReported

The date that the interpreting physician dictated this report. The transcriptionist enters this date from the dictation tape. If the physician is using a voice recognition system for dictation, this date is entered at the time the report is transmitted to DHCP.

«II» Id identifier identifier

Uniquely identifies the Report.

ImageInstance image image

Image assocated with this Report

String impressionText impressionText

'Impression text' of the rad/nuc med exam associated with this report. The 'impression text' gives a quick summary of the 'report text'.

MedicalImagingEvent relatedCase relatedCase

Related case to this report

String reportText reportText

Contains the report text for the imaging exam. The report text is written by the interpreting physician and may be entered into the system by a transcriptionist.

«CS» Code status status

Iindicate the status of this report. Possible values are Verified; Released/Not Verified; Problem Draft; Draft.

Attributes inherited from FHIM::Common::ClinicalStatement FHIM::Common::ClinicalStatement
clinicalDataSource clinicalDataSource, contentVersion contentVersion, contextCode contextCode, encounter encounter, note note, recordStatus recordStatus, relatedClinicalInformation relatedClinicalInformation, sourceRecordType sourceRecordType, sourceSystem sourceSystem, subjectGroup subjectGroup, subjectOfInformation subjectOfInformation, subjectOfRecord subjectOfRecord, temporalContext temporalContext, topicCode topicCode, cosigned cosigned, recorded recorded, signed signed, verified verified

Attributes inherited from FHIM::Common::InformationEntry FHIM::Common::InformationEntry
identifier identifier

Properties:

Alias
Classifier Behavior
Is Abstractfalse
Is Activefalse
Is Leaffalse
Keywords
NameImageInterpretationReport
Name Expression
NamespaceImaging
Owned Template Signature
OwnerImaging
Owning Template Parameter
PackageImaging
Qualified NameFHIM::Imaging::ImageInterpretationReport
Representation
Stereotype
Template Parameter
VisibilityPublic

Attribute Details

 additionalClinicalHistory
Public String additionalClinicalHistory

Contain a patient's clinical history as well as instructions to the interpreting physician. For example, the instructions might be for the physician to interpret the exam images to rule out the possibility of the patient having a certain disease. The 'additional clinical history' is written by the interpreting physician and is entered into the system by the transcriptionist. Voice Recognition systems allow the interpreting physician to directly enter this information into the 'additional clinical history' field.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameadditionalClinicalHistory
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::additionalClinicalHistory
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 dateEntered
Public «TS» PointInTime dateEntered

The date and time that the report was entered into the system by the transcriptionist.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedateEntered
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::dateEntered
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 dateReported
Public «TS» PointInTime dateReported

The date that the interpreting physician dictated this report. The transcriptionist enters this date from the dictation tape. If the physician is using a voice recognition system for dictation, this date is entered at the time the report is transmitted to DHCP.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedateReported
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::dateReported
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 identifier
Public «II» Id identifier

Uniquely identifies the Report.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Nameidentifier
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::identifier
Stereotype
Template Parameter
Type«II» Id
Upper1
Upper Value(1)
VisibilityPublic


 image
Public ImageInstance image

Image assocated with this Report

Constraints:
Properties:

AggregationNone
Alias
AssociationimageInterpretationReport_image
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameimage
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::image
Stereotype
Template Parameter
TypeImageInstance
Upper1
Upper Value(1)
VisibilityPublic


 impressionText
Public String impressionText

'Impression text' of the rad/nuc med exam associated with this report. The 'impression text' gives a quick summary of the 'report text'.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameimpressionText
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::impressionText
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 relatedCase
Public MedicalImagingEvent relatedCase

Related case to this report

Constraints:
Properties:

AggregationNone
Alias
AssociationimageInterpretationReport_relatedCase
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower1
Lower Value(1)
Multiplicity1
NamerelatedCase
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::relatedCase
Stereotype
Template Parameter
TypeMedicalImagingEvent
Upper1
Upper Value(1)
VisibilityPublic


 reportText
Public String reportText

Contains the report text for the imaging exam. The report text is written by the interpreting physician and may be entered into the system by a transcriptionist.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamereportText
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::reportText
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 status
Public «CS» Code status

Iindicate the status of this report. Possible values are Verified; Released/Not Verified; Problem Draft; Draft.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassImageInterpretationReport
Terminologies[
HL7_FHIR_R4 ImagingStudyStatus http://hl7.org/fhir/ValueSet/imagingstudy-status
]
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namestatus
Name Expression
NamespaceImageInterpretationReport
Opposite
OwnerImageInterpretationReport
Owning Association
Owning Template Parameter
Qualified NameFHIM::Imaging::ImageInterpretationReport::status
StereotypeValueSetConstraints
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic