ID

5840

Beschreibung

Diagnostic Imaging Report LOINC 18748-4 converted from CDA template

Stichworte

Versionen (1)
  1. 30.09.14 30.09.14 - Martin Dugas
Hochgeladen am

30. September 2014

DOI

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Lizenz

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

Englisch

Diagnostic Imaging Report (CDA)

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

ClinicalDocument

Title of Report
Beschreibung

Title of Report

Datentyp

text

Given name
Beschreibung

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

Datentyp

text

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

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

Datentyp

text

Alias
UMLS CUI-1
C0421448
Patient gender
Beschreibung

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

Datentyp

text

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

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

Datentyp

date

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

Documentation time (author.time.value)

Datentyp

time

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

Service event code
Beschreibung

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

datetime

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

Alias
UMLS CUI-1
C1998467
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Ähnliche Modelle

Diagnostic Imaging Report (CDA)

1 Formulare
  1. StudyEvent: Chest X-Ray, PA and LAT View
    1. Diagnostic Imaging Report (CDA)
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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