Xt-EHR Imaging Report Data Elements Analysis
Source Model: EHDSImagingReport v0.2.1
Analysis Date: October 2025
Model Version: Xt-EHR FHIR IG v0.2.1 (October 10, 2025)
Model Overview
The Xt-EHR Imaging Report model (EHDSImagingReport) provides a comprehensive structure for diagnostic imaging reports within the European Health Data Space (EHDS). This analysis examines each data element for real-world usage patterns and implementation priority.
Model Reference
Logical: EHDSImagingReport
Title: "Imaging report model"
Parent: EHDSDocument
Description: """Imaging report reflects the observations and interpretations
of one or more imaging studies, contains elements such as the reason why the
study is requested, relevant contextual medical information, the modality used
to acquire images and its settings, procedures and body localisations that
were used, a description of the observations and findings, exposure information,
conclusion and advice."""
Source: imagingReport.fsh
Legend
- Cardinality:
1..1 = Required (exactly one)1..* = Required (one or more)0..1 = Optional (zero or one)0..* = Optional (zero or more)- Base Elements: Elements with Status="Base" (fundamental to the model)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Subject |
header.subject |
1..1 |
Base |
EHDSPatient |
Patient/subject information |
| Identifier |
header.identifier |
1..* |
Base |
Identifier |
Unique identifier of the document |
| Authorship |
header.authorship |
1..* |
Base |
Base |
Report authoring details |
| Author |
header.authorship.author[x] |
1..1 |
Base |
Choice |
Author by whom the document was authored |
| Authoring DateTime |
header.authorship.datetime |
1..1 |
Base |
dateTime |
Date and time of authoring/issuing |
| Status |
header.status |
1..1 |
Base |
CodeableConcept |
Status of the document |
| Document Type |
header.documentType |
1..1 |
Base |
CodeableConcept |
Type of document (medical imaging report) |
| Document Title |
header.documentTitle |
1..1 |
Base |
string |
Human readable document title |
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Last Update |
header.lastUpdate |
0..1 |
Base |
dateTime |
Date and time of the last update |
| Status Reason |
header.statusReason[x] |
0..1 |
Base |
Choice |
Reason for the current status |
| Language |
header.language |
0..1 |
Base |
CodeableConcept |
Language in which the resource is written |
| Period |
header.period |
0..1 |
Base |
Period |
Time of service being documented |
| Version |
header.version |
0..1 |
Base |
string |
Business version of the document |
| Attestation |
header.attestation |
0..* |
Base |
Base |
Document attestation details |
| Legal Authentication |
header.legalAuthentication |
0..1 |
Base |
Base |
Document legal authentication details |
| Event Type |
header.eventType |
0..* |
Base |
CodeableConcept |
Categorisation of the event covered |
| Service Specialty |
header.serviceSpecialty |
0..* |
Base |
CodeableConcept |
Clinical specialty details |
| Custodian |
header.custodian |
0..1 |
Base |
EHDSOrganisation |
Organisation maintaining the document |
| Confidentiality |
header.confidentiality |
0..1 |
Base |
CodeableConcept |
Level of confidentiality |
| Accession Number |
header.accessionNumber |
0..1 |
Base |
string |
RIS identifier for the imaging procedure |
| Health Insurance Info |
header.healthInsuranceAndPaymentInformation |
0..* |
Base |
EHDSCoverage |
Health insurance and payment information |
| Intended Recipient |
header.intendedRecipient[x] |
0..* |
Base |
Choice |
Information recipient |
Body Section (Optional: 0..1)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Order ID |
body.orderInformation.orderId |
1..* |
Base |
Identifier |
Identifier(s) of the imaging service order |
| Order Date Time |
body.orderInformation.orderDateAndTime |
0..1 |
Base |
dateTime |
Date and time of the order placement |
| Order Placer |
body.orderInformation.orderPlacer[x] |
0..1 |
Base |
Choice |
Person/organisation placing the order |
| Order Reason Text |
body.orderInformation.orderReasonText |
0..* |
Base |
string |
Textual explanation for the service request |
| Order Reason |
body.orderInformation.orderReason[x] |
0..* |
Base |
Choice |
Coded explanation for the service request |
| Clinical Question |
body.orderInformation.clinicalQuestion |
0..1 |
Base |
string |
Clinical question to be answered |
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Observation |
body.supportingInformation.observation |
0..* |
Base |
EHDSObservation |
Clinical findings and observations |
| Condition |
body.supportingInformation.condition |
0..* |
Base |
EHDSCondition |
Conditions affecting service/interpretation |
| Medication Administration |
body.supportingInformation.medicationAdministration |
0..* |
Base |
EHDSMedicationAdministration |
Medications for the procedure |
| Devices |
body.supportingInformation.devices |
0..* |
Base |
EHDSDevice |
Implants/devices affecting examination |
| Pregnancy Status |
body.supportingInformation.pregnancyStatus |
0..1 |
Base |
EHDSCurrentPregnancy |
Pregnancy status during examination |
| Sex for Clinical Use |
body.supportingInformation.sexForClinicalUse |
0..* |
Base |
CodeableConcept |
Sex parameter for clinical decision making |
| Other Supporting Info |
body.supportingInformation.otherSupportingInformation |
0..* |
Base |
Resource |
Any other relevant supporting information |
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Specimen |
body.specimen |
0..* |
Base |
EHDSSpecimen |
Specimen information |
Service Request (Optional: 0..*)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Service Request |
body.serviceRequest |
0..* |
Base |
EHDSServiceRequest |
Specification of requested service(s) |
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Effective Dose |
body.exposureInformation.effectiveDose |
0..* |
Base |
Quantity |
Effective dose in mSv |
| Equivalent Dose Info |
body.exposureInformation.equivalentDoseInformation |
1..1 |
Base |
Base |
Equivalent dose information |
| Equivalent Dose |
body.exposureInformation.equivalentDoseInformation.equivalentDose |
1..1 |
Base |
Quantity |
Equivalent dose in mSv |
| Tissue Type |
body.exposureInformation.equivalentDoseInformation.tissueType |
1..1 |
Base |
CodeableConcept |
Type of tissue for dosage enumeration |
Examination Report Section (Required if body present: 1..1)
Core Examination Elements
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Modality |
body.examinationReport.modality |
1..* |
Base |
CodeableConcept |
Imaging modality used |
| Body Part |
body.examinationReport.bodyPart |
0..* |
Base |
EHDSBodyStructure |
All body parts investigated |
| Imaging Procedures |
body.examinationReport.imagingProcedures |
0..* |
Base |
EHDSProcedure |
Imaging procedures performed |
| Medication |
body.examinationReport.medication |
0..* |
Base |
EHDSMedicationAdministration |
Medication administered (contrast, etc.) |
| Adverse Reaction |
body.examinationReport.adverseReaction |
0..* |
Base |
EHDSAllergyIntolerance |
Adverse reactions during investigation |
Result Data (Optional: 0..1)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Result Text |
body.examinationReport.resultData.resultText |
1..1 |
Base |
string |
Narrative representation of results |
| Observation Results |
body.examinationReport.resultData.observationResults |
0..* |
Base |
EHDSObservation |
Detailed observation results |
Conclusion (Required if examination report present: 1..1)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Impression |
body.examinationReport.conclusion.impression |
1..1 |
Base |
string |
Narrative clinical conclusion |
| Condition or Finding |
body.examinationReport.conclusion.conditionOrFinding[x] |
0..* |
Base |
Choice |
Structured findings from investigation |
Recommendation (Optional: 0..1)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Description |
body.recommendation.description |
1..1 |
Base |
string |
Narrative description of recommendations |
| Care Plan |
body.recommendation.carePlan |
0..* |
Base |
EHDSCarePlan |
Structured care plan information |
Comparison Study (Optional: 0..*)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Comparison Study |
body.comparisonStudy |
0..* |
Base |
EHDSImagingReport |
Reference to prior imaging reports |
Additional Sections
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| DICOM Study Metadata |
dicomStudyMetadata |
0..* |
Base |
EHDSImagingStudy |
Metadata of the DICOM study |
Attachments (Optional: 0..*)
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Attachments |
attachments[x] |
0..* |
Base |
Choice |
Report attachments |
| Element |
Path |
Cardinality |
Status |
Type |
Description |
| Presented Form |
presentedForm |
0..* |
Base |
EHDSAttachment |
PDF version or narrative representation |
Summary Statistics
Required Elements (Base Status)
- Always Required (1..1 or 1..*): 8 elements
- Conditionally Required: 4 elements (when parent is present)
Optional Elements (Base Status)
- Header Optional: 11 elements
- Body Optional: 25+ elements
- Total Optional: 35+ elements
Total Base Elements: ~47 elements
Notes
- All elements listed have "Base" status in the terminology bindings
- Choice elements (indicated by [x]) can have multiple type options
- Complex elements contain sub-elements that expand the total count
- Many optional elements are designed for comprehensive clinical documentation
- Required elements focus on core identification, authorship, and clinical findings