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, or series of examinations, 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. More complex procedures (such as echocardiaograms or Bone density scans) may be represented using templates or specialised archetypes where additional report content is appropriate. 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 or activities. For example when imaging is performed as part of a procedure the information related to the procedure must be recorded using the ACTION.procedure archetype or an OBSERVATION for the operative findings. This archetype will only be used to record the findings from the imaging. Not to be used to record details about any parallel procedure undertaken. Use the specific procedure-related archetypes, for example ACTION.procedure. Not to be used to record 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, or series of examinations, performed.
ReferencesDerived from: <Add reference to original resource here>
IHE.net Technical Frameworks - Radiology [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.ihe.net/Technical_Framework/index.cfm#radiology

RSNA.org: Radiology Reporting [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.rsna.org/Informatics/radreports.cfm

Radiology Written Report Guideline Project (Draft Consultation); December 2010.

Diagnostic Imaging data specifications; NEHTA, version 1.0, 2007 Jun 29.

Imaging examination result, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. London: NEHTA. Authored: 11 Feb 2007. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.943_6 (accessed 16 Sep 2013).
Copyright© openEHR Foundation, HiGHmed
AuthorsAuthor name: Grahame Grieve
Organisation: Health Intersections Pty Ltd
Email: grahame@healthintersections.com.au
Date originally authored: 2011-02-07
Other Details LanguageAuthor name: Grahame Grieve
Organisation: Health Intersections Pty Ltd
Email: grahame@healthintersections.com.au
Date originally authored: 2011-02-07
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=HiGHmed, references=Derived from: IHE.net Technical Frameworks - Radiology [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.ihe.net/Technical_Framework/index.cfm#radiology RSNA.org: Radiology Reporting [Internet]. [date unknown];[cited 2011 Jan 2 ] Available from: http://www.rsna.org/Informatics/radreports.cfm Radiology Written Report Guideline Project (Draft Consultation); December 2010. Diagnostic Imaging data specifications; NEHTA, version 1.0, 2007 Jun 29. Imaging examination result, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. London: NEHTA. Authored: 11 Feb 2007. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.943_6 (accessed 16 Sep 2013)., original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=FF790AEFE0237D3419F47E15CBF986A6, build_uid=321ad050-ee44-4763-9808-e8391c32dee4, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID659b9513-677c-4ef8-a3e6-decd2eb6d0bd
Language useden
Citeable Identifier1246.145.65
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Record the findings and interpretation of an imaging examination, or series of examinations, performed., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Nasjonal IKT HF, 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 Pyty Ltd, Australia (Editor)
Mary Kelaher, NEHTA, Australia
Diane Kirkham, NEHTA, Australia
Robert L'egan, NEHTA, Australia
Heather Leslie, Ocean Health Systems, 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
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
Don Stewart
Michael Thompson, Queensland Health, Australia
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia, originalLanguage=en, translators=German: Ramona Wellmann, Medizinische Hochschule Hannover, wellmann.ramona@mh-hannover.de
Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF, Norway
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={relationships=[], provider=[], details=[], description=[], capabilities=[], activities=[], contacts=[], content=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0026], code=at0026, itemType=SLOT, level=2, text=Receiving imaging service, description=Demographic details about the receiving imaging service performing the imaging test., 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[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=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., 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[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:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=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., 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[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=3, 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[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=3, text=Image details, description=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., 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[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=4, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., 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[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=DICOM series identifier, description=Unique identifier of this 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[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Position, description=Description of the subject of care's positon when the image was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=4, text=Image DateTime, description=Specific date/time the imaging examination was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0041], code=at0041, itemType=SLOT, level=2, text=Examination procedure, description=Additional structured details of imaging examination methodology followed. For example, structured details about the examination technique, prepraration or contrast medium used., 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[at0042], code=at0042, itemType=CLUSTER, level=2, text=Compared image details, description=Details of previous images used for comparison., 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[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[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., 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[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=3, text=DICOM series identifier, description=Unique identifier of this 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[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=3, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=3, text=Position, description=Description of the subject of care's positon when the image was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=3, text=Image DateTime, description=Specific date/time the imaging examination was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=3, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., 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]], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: 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=The imaging method used to perform the examination., comment=For example: Ultrasound, CT, 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 is not required., 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[at0043], code=at0043, itemType=ELEMENT, level=4, text=Submodality, description=Imaging submodality where further classification of imaging modality is required., comment=Coding with a terminology is desirable, where possible., 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=Anatomical site, description=Details of the anatomical site of imaging examination, including laterality, if all individual findings and results are related to the same anatomical location. If the anatomical site is sufficiently specified with a code in the Examination test name, then this additional data is not required. Finer-grained multiple anatomical sites may be represented per ‘Result group’., 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.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[at0014], code=at0014, itemType=ELEMENT, level=4, text=Clinical information provided, description=Description of clinical information available at the time of interpretation of results, and which may a link to the original clinical information provided in the examination request., 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[at0008], code=at0008, itemType=ELEMENT, level=4, text=Findings, description=Narrative description of findings, including comparative 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=Imaging result, description=Slot for detailed structured description of the imaging 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.imaging_result.v0 and specialisations, 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 'Conclusion'., comment=Coding with a terminology is preferred, where possible., 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[at0021], code=at0021, itemType=ELEMENT, level=4, text=Conclusion, description=Concise and clinically contextualised narrative interpretation of the imaging examination 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[at0045], code=at0045, itemType=SLOT, level=4, text=Examination result representation, description=Digital image, video or diagram representing the exam 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.multimedia.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, recommendations for future examinations; a comment on appropriateness of the examination or on quality of images, if separate to findings; or 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]], source=[], 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 test 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]], 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]], items=[], target=[], identities=[], credentials=[], other_participations=[], ism_transition=[], context=[]}, topLevelItems={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=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], 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=1..1, cardinalityText=mandatory, 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=1..1, cardinalityText=mandatory, 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=Receiving imaging service, description=Demographic details about the receiving imaging service performing the imaging test., 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[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=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., 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[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:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=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., 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[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=3, 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[at0027]/items[at0034], code=at0034, itemType=CLUSTER, level=3, text=Image details, description=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., 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[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=4, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., 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[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=DICOM series identifier, description=Unique identifier of this 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[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Position, description=Description of the subject of care's positon when the image was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=4, text=Image DateTime, description=Specific date/time the imaging examination was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0041], code=at0041, itemType=SLOT, level=2, text=Examination procedure, description=Additional structured details of imaging examination methodology followed. For example, structured details about the examination technique, prepraration or contrast medium used., 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[at0042], code=at0042, itemType=CLUSTER, level=2, text=Compared image details, description=Details of previous images used for comparison., 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[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[at0032], code=at0032, itemType=ELEMENT, level=3, text=DICOM study identifier, description=Unique identifier of this study allocated by the imaging service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0027]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Image identifier, description=Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)., 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[at0034]/items[at0036], code=at0036, itemType=ELEMENT, level=3, text=DICOM series identifier, description=Unique identifier of this 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[at0027]/items[at0034]/items[at0037], code=at0037, itemType=ELEMENT, level=3, text=View, description=The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0038], code=at0038, itemType=ELEMENT, level=3, text=Position, description=Description of the subject of care's positon when the image was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=3, text=Image DateTime, description=Specific date/time the imaging examination was performed., 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=/protocol[at0025]/items[at0027]/items[at0034]/items[at0040], code=at0040, itemType=ELEMENT, level=3, text=Image, description=An attached or referenced image of a current view., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=application/dicom, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0025]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., 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]