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Diagnostic Imaging

Data Element

Applicable Standard(s)

Diagnostic Imaging Narrative
  • Diagnostic Imaging Study (LOINC® code 18748-4)
  • This data element was reclassified from Clinical Notes to Diagnostic Imaging.
Diagnostic Imaging Order
  • Logical Observation Identifiers Names and Codes (LOINC®) Database version 2.69
Diagnostic Imaging Report
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.69

Comment

More than just radiology images

Should clarify that Diagnostic Imaging applies to colonoscopies, retinal images, cardiac ultrasounds, etc., all of which carry images and not just radiology images. Need more guidance about when to use the following code. Same issues as for  narrative pathology and laboratory reports. 18748-4 Diagnostic imaging study Diagnostic Imaging Report (DIR) contains a consulting specialist's interpretation of image data. It conveys the interpretation to the referring (ordering) physician and is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

Common pattern needed for Diagnostic Imaging Data Elements

To present a more consistent way of putting forth testing for Diagnostic Imaging, (consistent with Laboratory and Pathology information too), we recommend creating a consistent set of data elements and a similar set of definitions and relationships.  The Order expresses the test when it is in an “ordered” state whereas the Test (same notion as "study/exam"), expresses the test when it is in a “completed” state.  The value/result is the measured value determined by the test as its “results”. The report contains information about the order, the test and the value/result along with other narrative explaining the assessment of the results.

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