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  1. FHIR Specification Feedback
  2. FHIR-34958

Imaging DiagnosticReport ontology

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    • Change Request
    • Status: Published (View Workflow)
    • Highest
    • Resolution: Persuasive with Modification
    • US Core (FHIR)
    • 4.0.0
    • Cross-Group Projects
    • US Core DiagnosticReport Profile for Report and Note Exchange
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      Background:

      Here is the applicable Vocabulary for USCDI V2

      (source: https://www.healthit.gov/isa/sites/isa/files/2021-07/USCDI-Version-2-July-2021-Final.pdf)

      The commenter is referencing this section of HL7 CCDA:

      codes defined in CONF-DIR-19 to DiagnosticReport.code:

      ...TODO...

       

      Reasoning:

       We agree to add some implementation guidance on terminology for diagnostic imaging.

      We disagree that detailed guidance for population of the  DiagnosticReport.text and DiagnosticReport.conclusion is appropriate.  That level of detailed guidance for elements not defined in the profile is more appropriately documented by an implementation community using this profile.

      Proposed Changes:

      Add the following implementation guidance to the Profile specific implementation guidance:

      • For Diagnostic Imaging Reports systems SHOULD support using the subset of  LOINC codes defined in CONF-DIR-19 in DiagnosticReport.code
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      Background: Here is the applicable Vocabulary for USCDI V2 (source: https://www.healthit.gov/isa/sites/isa/files/2021-07/USCDI-Version-2-July-2021-Final.pdf ) The commenter is referencing this section of HL7 CCDA: codes defined in CONF-DIR-19 to DiagnosticReport.code: ...TODO...   Reasoning:  We agree to add some implementation guidance on terminology for diagnostic imaging. We disagree that detailed guidance for population of the  DiagnosticReport.text and DiagnosticReport.conclusion is appropriate.  That level of detailed guidance for elements not defined in the profile is more appropriately documented by an implementation community using this profile. Proposed Changes: Add the following implementation guidance to the  Profile specific implementation guidance: For Diagnostic Imaging Reports systems  SHOULD  support using the subset of  LOINC codes defined in CONF-DIR-19 in DiagnosticReport.code
    • Eric Haas / Isaac Vetter : 13-0-0
    • Correction
    • Non-substantive

    Description

      The USCDI submission references LOINC codes

      The Clinical Notes Guidance, Imaging Narrative Clinical note references LOINC and creates consistency with CDA (Implementation Guide for CDA Release 2: Imaging Integration Levels 1, 2, and 3 Basic Imaging Reports in CDA and DICOM Diagnostic Imaging Reports (DIR) - Universal Realm Based on HL7 CDA Release 2.0 Release 1.0)

      For additional consistency, consider:  

      • Add LOINC codes defined in CONF-DIR-19 to DiagnosticReport.code
      • Reference both DICOM and LOINC code systems in DiagnosticReport.text and DiagnosticReport.conclusion

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              Unassigned Unassigned
              steven_nichols Steven Nichols
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                Updated:
                Resolved: