Diagnostic Imaging Report
A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient's medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties. Note: this document type overlaps with the FHIR DiagnosticReport resource. Most use cases will want to use the specific resource type, but this document type is still useful for CDA to FHIR conversion and other such use cases.
Profile Name
DiagnosticImagingReport
Base Definition
Derivation
constraint
Differential Elements (47)
Constraints and modifications from the base definition
| Path | Cardinality | Type(s) | Must Support | Details |
|---|---|---|---|---|
Composition | - | - | - | - |
Composition.type | - | - | Yes | - |
Composition.section | - | - | - | - |
Composition.sectionSlice: findings_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: findings_entry | - | Reference | Yes | Target: Observation |
Composition.sectionSlice: dicom_object_catalog_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: dicom_object_catalog_entry | - | Reference | Yes | Target: ImagingStudy |
Composition.sectionSlice: history_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: request_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: current_procedure_descriptions_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: prior_procedure_descriptions_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: previous_findings_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: impressions_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: recommendations_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: conclusions_section | 0..1 | BackboneElement | Yes | - |
Composition.section.title | - | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |