---
title: Module Report Radiologi
tags: fhir-module-id
disqus: victoriatjia
---
Module Report Radiologi
===
###### tags: `fhir-module-id` `satu-sehat`
## Table of Contents
[TOC]
## Pendahuluan
Informasi data pasien
## Specs Data Format
### 1. [FHIR Encounter](https://www.hl7.org/fhir/encounter.html)
#### 1.1. Deskripsi
Kunjungan pasien dapat didefinisikan sebagai interaksi pasien terhadap suatu layanan fasyankes.
Misal dalam satu rangkaian rawat jalan, seluruh rangkaian dapat didefinisikan sebagai satu “Encounter”
#### 1.2. Spesifikasi data format -> [link](https://github.com/victoriatjia/Guideline/blob/master/SatuSehat/Specs%20Format%20FHIR/custom/Encounter.xlsx)
#### 1.3. Scenario
<table>
<tr>
<td><b>Scenario 1</b></td>
<td>Kunjungan Pasien</td>
</tr>
</table>
**Example SC1**: Kunjungan Pasien Rawat Jalan
https://hapi.fhir.org/baseR4/Encounter/edba8523-9745-4d6b-9771-61d1c9c7c933
```gherkin=
{
"resourceType": "Encounter",
"id": "edba8523-9745-4d6b-9771-61d1c9c7c933",
"meta": {
"versionId": "1",
"lastUpdated": "2022-11-14T01:23:28.123+00:00",
"source": "#ujBBhsfic45Hwsua"
},
"identifier": [ {
"use": "official",
"system": "http://sys-ids.kemkes.go.id/encounter/10000004",
"value": "O0000000001"
} ],
"status": "finished",
"class": {
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "AMB",
"display": "ambulatory"
},
"subject": {
"reference": "Patient/7058523",
"display": "Hannah Mid Vlixie"
},
"participant": [ {
"type": [ {
"coding": [ {
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "ATND"
} ]
} ],
"individual": {
"reference": "Practitioner/8xx5",
"display": "Marcia, drg, Sp.PM"
}
} ],
"period": {
"start": "2022-06-17T16:00:00+07:00",
"end": "2022-06-17T16:30:00+07:00"
},
"location": [ {
"location": {
"reference": "Location/7062759",
"display": "Neurology Clinic (2nd fl)"
}
} ],
"serviceProvider": {
"reference": "Organization/tch"
}
}
```
---
### 2. [FHIR ServiceRequest](https://www.hl7.org/fhir/servicerequest.html)
#### 2.1. Deskripsi
Sebelum melakukan pemeriksaan penunjang seperti laboratorium, diperlukan langkah permintaan
pemeriksaan penunjang menggunakan resource ServiceRequest.
#### 2.2. Spesifikasi data format -> [link](https://github.com/victoriatjia/Guideline/blob/master/SatuSehat/Specs%20Format%20FHIR/custom/ServiceRequest.xlsx)
#### 2.3. Scenario
<table>
<tr>
<td><b>Scenario 1</b></td>
<td>Permintaan pemeriksaan radiology</td>
</tr>
</table>
**Example SC1**: Kunjungan Pasien Rawat Jalan
https://hapi.fhir.org/baseR4/ServiceRequest/9a0ec019-be03-4054-826b-d7ebef1c25f9
```gherkin=
{
"resourceType": "ServiceRequest",
"id": "9a0ec019-be03-4054-826b-d7ebef1c25f9",
"meta": {
"versionId": "1",
"lastUpdated": "2022-11-14T01:25:16.389+00:00",
"source": "#M1c1KVZT8Y5NRyJ3"
},
"identifier": [ {
"system": "http://tzuchihospital.co.id/fhir/identifier/OEORI_RowId",
"value": "1||4"
} ],
"status": "completed",
"category": [ {
"coding": [ {
"system": "http://tzuchihospital.co.id/cs/order-category",
"code": "RAD",
"display": "TCH Radiology"
} ]
} ],
"code": {
"coding": [ {
"system": "http://tzuchihospital.co.id/cs/",
"code": "190701002083",
"display": "DX - Thorax AP / PA"
} ]
},
"subject": {
"reference": "Patient/7058523"
},
"encounter": {
"reference": "Encounter/edba8523-9745-4d6b-9771-61d1c9c7c933"
},
"occurrenceDateTime": "2021-04-21T08:00:00",
"requester": {
"reference": "Practitioner/8xx5"
},
"performer": [ {
"reference": "Practitioner/8xx5"
} ]
}
```
---
### 3. [draft] [FHIR ImagingStudy](https://www.hl7.org/fhir/imagingstudy.html)
#### 3.1. Deskripsi
Detail lengkap imaging terkait laporan hasil radiologi menggunakan DICOM
#### 3.2. Spesifikasi data format -> [upload soon]<!--(https://github.com/victoriatjia/Guideline/blob/master/SatuSehat/Specs%20Format%20FHIR/custom/ImagingStudy.xlsx)-->
#### 3.3. Scenario
<table>
<tr>
<td><b>Scenario 1</b></td>
<td>Radiology Image</td>
</tr>
</table>
**Example SC1**: Radiology Image
https://hapi.fhir.org/baseR4/ImagingStudy/misac.dicom.image01
<!--
```gherkin=
{
"resourceType": "ImagingStudy",
"identifier": [
{
"use": "official",
"system": "urn:dicom:uid",
"value": "urn:oid:1.2.1124.113532.134.0.1.3.20030423.143824.800378"
}
],
"status": "available",
"modality": [
{
"coding": [
{
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "MG"
}
]
}
],
"subject": {
"reference": "Patient/1168613"
},
"encounter": {
"reference": "Encounter/6947773"
},
"started": "2022-08-06T11:01:20+03:00",
"basedOn": [
{
"type": "ServiceRequest",
"identifier": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN"
}
]
}
}
},
{
"reference": "ServiceRequest/6947777"
}
],
"referrer": {
"reference": "Practitioner/example"
},
"interpreter": [
{
"reference": "Practitioner/radiologist"
}
],
"endpoint": [
{
"reference": "Endpoint/example-wadors"
}
],
"numberOfSeries": 4,
"numberOfInstances": 4,
"series": [
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.98.1",
"number": 1,
"modality": {
"coding": [
{
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "MG"
}
]
},
"description": "MG R CC",
"numberOfInstances": 1,
"performer": [
{
"function": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "PRF"
}
]
},
"actor": {
"reference": "Practitioner/radiographer"
}
}
],
"instance": [
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.104.1",
"sopClass": {
"system": "urn:ietf:rfc:3986",
"code": "urn:oid:1.2.840.10008.5.1.4.1.1.1.2"
},
"number": 1
}
]
},
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.99.1",
"number": 2,
"modality": {
"coding": [
{
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "MG"
}
]
},
"description": "MG L CC",
"numberOfInstances": 1,
"performer": [
{
"function": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "PRF"
}
]
},
"actor": {
"reference": "Practitioner/radiographer"
}
}
],
"instance": [
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.102.1",
"sopClass": {
"system": "urn:ietf:rfc:3986",
"code": "urn:oid:1.2.840.10008.5.1.4.1.1.1.2"
},
"number": 1
}
]
},
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.100.1",
"number": 3,
"modality": {
"coding": [
{
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "MG"
}
]
},
"description": "MG L MLO",
"numberOfInstances": 1,
"endpoint": [
{
"reference": "Endpoint/example-wadors"
}
],
"performer": [
{
"function": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "PRF"
}
]
},
"actor": {
"reference": "Practitioner/radiographer"
}
}
],
"instance": [
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.106.1",
"sopClass": {
"system": "urn:ietf:rfc:3986",
"code": "urn:oid:1.2.840.10008.5.1.4.1.1.1.2"
},
"number": 1
}
]
},
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.101.1",
"number": 4,
"modality": {
"coding": [
{
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "MG"
}
]
},
"description": "MG R MLO",
"numberOfInstances": 1,
"performer": [
{
"function": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "PRF"
}
]
},
"actor": {
"reference": "Practitioner/radiographer"
}
}
],
"instance": [
{
"uid": "1.2.1840.113681.2198909122.3931.3228559234.108.1",
"sopClass": {
"system": "urn:ietf:rfc:3986",
"code": "urn:oid:1.2.840.10008.5.1.4.1.1.1.2"
},
"number": 1
}
]
}
]
}
```
-->
---
### 4. [FHIR DiagnosticReport](https://www.hl7.org/fhir/diagnosticreport.html)
#### 4.1. Deskripsi
Laporan hasil pemeriksaan
#### 4.2. Spesifikasi data format -> [link](https://github.com/victoriatjia/Guideline/blob/master/SatuSehat/Specs%20Format%20FHIR/custom/DiagnosticReport.xlsx)
#### 4.3. Scenario
<table>
<tr>
<td><b>Scenario 1</b></td>
<td>Radiology Report</td>
</tr>
</table>
**Example SC1**: Radiology Report
https://hapi.fhir.org/baseR4/DiagnosticReport/73c7e525-8782-4efb-ac39-7ec3b13e5b68
```gherkin=
{
"resourceType": "DiagnosticReport",
"id": "73c7e525-8782-4efb-ac39-7ec3b13e5b68",
"meta": {
"versionId": "2",
"lastUpdated": "2022-11-14T01:37:38.816+00:00",
"source": "#acGo6p8K7ZZPmCnt"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><div class=\"hapiHeaderText\"> DX - Thorax AP / PA </div><table class=\"hapiPropertyTable\"><tbody><tr><td>Status</td><td>FINAL</td></tr><tr><td>Issued</td><td> 27 September 2021 </td></tr><tr><td>Conclusion</td><td><html><head></head><body>Telah dilakukan radiografi toraks proyeksi PA, dengan hasil:<br />&#160;<br />Jantung tidak membesar<br />Aorta dan mediastinum superior tidak melebar.<br />Trakea di tengah. Kedua hilus tidak menebal.<br />Corakan bronkovaskular kedua paru baik.<br />Tidak tampak infiltrat di kedua paru<br />Sinus kostofrenikus dan diafragma baik.<br />Tulang-tulang dan jaringan lunak dinding dada baik.<br />&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;<br />Kesimpulan :<ul><li>Tak tampak kardiomegali.</li><li>Tidak tampak infiltrat di kedua paru.</li></ul></body></html></td></tr></tbody></table></div>"
},
"identifier": [ {
"use": "official",
"system": "RPTRAD_RowId",
"value": "120121"
}, {
"use": "official",
"system": "http://sys-ids.kemkes.go.id/accession-no/10000004",
"value": "120121/142"
} ],
"basedOn": [ {
"reference": "ServiceRequest/9a0ec019-be03-4054-826b-d7ebef1c25f9"
} ],
"status": "final",
"category": [ {
"coding": [ {
"system": "https://terminology.hl7.org/2.0.0/CodeSystem-v2-0074.html",
"code": "RAD",
"display": "RAD"
} ]
} ],
"code": {
"coding": [ {
"system": "http://tzuchihospital.co.id/cs/order-item",
"code": "190701002083",
"display": "DX - Thorax AP / PA"
} ],
"text": "DX - Thorax AP / PA"
},
"subject": {
"reference": "Patient/7058523"
},
"encounter": {
"reference": "Encounter/edba8523-9745-4d6b-9771-61d1c9c7c933"
},
"effectiveDateTime": "2021-09-27",
"issued": "2021-09-27",
"performer": [ {
"reference": "Practitioner/8xx5",
"display": "Maria Angelina Yashinta G Dr. Sp.Rad"
} ],
"resultsInterpreter": [ {
"reference": "Practitioner/8xx5",
"display": "Maria Angelina Yashinta G Dr. Sp.Rad"
} ],
"conclusion": "<html><head></head><body>Telah dilakukan radiografi toraks proyeksi PA, dengan hasil:<br /> <br />Jantung tidak membesar<br />Aorta dan mediastinum superior tidak melebar.<br />Trakea di tengah. Kedua hilus tidak menebal.<br />Corakan bronkovaskular kedua paru baik.<br />Tidak tampak infiltrat di kedua paru<br />Sinus kostofrenikus dan diafragma baik.<br />Tulang-tulang dan jaringan lunak dinding dada baik.<br />                                                                                                                       <br />Kesimpulan :<ul><li>Tak tampak kardiomegali.</li><li>Tidak tampak infiltrat di kedua paru.</li></ul></body></html>"
}
```
---
### 5. [FHIR Bundle](https://www.hl7.org/fhir/bundle.html)
#### 5.1. Deskripsi
Bundle laporan hasil pemeriksaan
#### 5.2. Spesifikasi data format -> [upload soon]<!--(https://github.com/victoriatjia/Guideline/blob/master/SatuSehat/Specs%20Format%20FHIR/custom/Bundle.xlsx)-->
#### 5.3. Scenario
<table>
<tr>
<td><b>Scenario 1</b></td>
<td>Bundle Radiology Report</td>
</tr>
</table>
**Example SC1**: Radiology Report
```gherkin=
```
Sign in with Wallet
Connect another wallet