ID

5840

Description

Diagnostic Imaging Report LOINC 18748-4 converted from CDA template

Keywords

Versions (1)
  1. 9/30/14 9/30/14 - Martin Dugas
Uploaded on

September 30, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Diagnostic Imaging Report (CDA)

English

Diagnostic Imaging Report (CDA)

1 forms  
  1. StudyEvent: Chest X-Ray, PA and LAT View
    1. Diagnostic Imaging Report (CDA)
ClinicalDocument
Description

ClinicalDocument

Title of Report
Description

Title of Report

Data type

text

Given name
Description

Given name (recordTarget.patientRole.patient.name.given)

Data type

text

Alias
UMLS CUI-1
C1299487
Family name (recordTarget.patientRole.patient.name.family)
Description

Family name (recordTarget.patientRole.patient.name.family)

Data type

text

Alias
UMLS CUI-1
C0421448
Patient gender
Description

Patient gender (recordTarget.patientRole.patient.administrativeGenderCode.code)

Data type

text

Alias
UMLS CUI-1
C0079399
Date of Birth (recordTarget.patientRole.patient.birthTime.value)
Description

Date of Birth (recordTarget.patientRole.patient.birthTime.value)

Data type

date

Alias
UMLS CUI-1
C0421451
Documentation time (author.time.value)
Description

Documentation time (author.time.value)

Data type

time

Document author given name (author.assignedAuthor.assignedPerson.name.given)
Description

Document author given name (author.assignedAuthor.assignedPerson.name.given)

Data type

text

Document author family name (author.assignedAuthor.assignedPerson.name.family)
Description

Document author family name (author.assignedAuthor.assignedPerson.name.family)

Data type

text

Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)
Description

Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)

Data type

text

Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)
Description

Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)

Data type

text

Service event code
Description

Service event code (documentationOf.serviceEvent.code.attributes.code), e.g. 70544 from codeSystemname CPT4

Data type

text

Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)
Description

Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)

Data type

text

Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)
Description

Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)

Data type

datetime

Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)
Description

Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)

Data type

text

Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology
Description

Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology

Data type

text

Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)
Description

Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)

Data type

text

Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)
Description

Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)

Data type

text

Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR
Description

Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR

Data type

text

Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography
Description

Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography

Data type

text

Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID
Description

Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID

Data type

text

Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage
Description

Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage

Data type

text

Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)
Description

Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)

Data type

text

Indications for procedure (component.structuredBody.component.section.text)
Description

Indications for procedure (component.structuredBody.component.section.text)

Data type

text

Medical history (component.structuredBody.component.section.text.paragraph.content)
Description

Medical history (component.structuredBody.component.section.text.paragraph.content)

Data type

text

Alias
UMLS CUI-1
C0262926
Findings (component.structuredBody.component.section.text.paragraph.content)
Description

Findings (component.structuredBody.component.section.text.paragraph.content)

Data type

text

Alias
UMLS CUI-1
C0243095
Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID)
Description

Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID), e.g. Diam2

Data type

text

Finding value (component.structuredBody.component.section.text.paragraph.content)
Description

Finding value (component.structuredBody.component.section.text.paragraph.content), e.g. 45mm

Data type

text

Alias
UMLS CUI-1
C0243095
Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source
Description

Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source

Data type

text

Impression (component.structuredBody.component.section.text.paragraph.content)
Description

Impression (component.structuredBody.component.section.text.paragraph.content)

Data type

text

Alias
UMLS CUI-1
C1998467
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Similar models

Diagnostic Imaging Report (CDA)

1 forms
  1. StudyEvent: Chest X-Ray, PA and LAT View
    1. Diagnostic Imaging Report (CDA)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Title of Report
Item
Title of Report
text
Patient name
Item
Given name
text
C1299487 (UMLS CUI-1)
Patient surname
Item
Family name (recordTarget.patientRole.patient.name.family)
text
C0421448 (UMLS CUI-1)
Gender
Item
Patient gender
text
C0079399 (UMLS CUI-1)
Date of Birth
Item
Date of Birth (recordTarget.patientRole.patient.birthTime.value)
date
C0421451 (UMLS CUI-1)
Documentation time
Item
Documentation time (author.time.value)
time
Document author given name
Item
Document author given name (author.assignedAuthor.assignedPerson.name.given)
text
Document author family name
Item
Document author family name (author.assignedAuthor.assignedPerson.name.family)
text
Information recipient given name
Item
Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)
text
Information recipient family name
Item
Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)
text
Service event code
Item
Service event code
text
Service event name
Item
Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)
text
Date and time of service event
Item
Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)
datetime
Performing entity code
Item
Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)
text
Performing entity name
Item
Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology
text
Performer given name
Item
Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)
text
Performer family name
Item
Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)
text
Modality code
Item
Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR
text
Modality name
Item
Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography
text
Storage System Code
Item
Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID
text
Storage System Name
Item
Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage
text
Reference to image
Item
Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)
text
Indications for procedure
Item
Indications for procedure (component.structuredBody.component.section.text)
text
Medical history
Item
Medical history (component.structuredBody.component.section.text.paragraph.content)
text
C0262926 (UMLS CUI-1)
Findings
Item
Findings (component.structuredBody.component.section.text.paragraph.content)
text
C0243095 (UMLS CUI-1)
Finding ID
Item
Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID)
text
Finding value
Item
Finding value (component.structuredBody.component.section.text.paragraph.content)
text
C0243095 (UMLS CUI-1)
Source of Measurement
Item
Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source
text
Impression
Item
Impression (component.structuredBody.component.section.text.paragraph.content)
text
C1998467 (UMLS CUI-1)
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