Grammar: DataElement 6.0
Namespace: breastrad
Description: "Breast Radiology Report"
Uses: shr.core, obf
CodeSystem: LOINC = http://loinc.org
CodeSystem: LISTORDER = http://terminology.hl7.org/CodeSystem/list-order

//
// BreastRadiologyReport Definition
// The contains the breast study sections and assocaited details. It is referenced by the BreastRadiologyDocument.
// This is derived from Composition.
//
Entry: BreastRadiologyDocument
Description: "Breast Radiology Report"
Parent: Composition
Property: SummaryBiRadCode 1..1										// Worst BiRad code in document
Property: BreastExamTechnique 1..*									// Breast exam technique
		Section
		includes PatientHistory 0..1								// Composition.Section Patient History Splice
		includes Findings 0..1										// Composition.Section Findings  Splice
		includes Impressions 0..1									// Composition.Section Impressions Splice
		includes Recommendations 0..1								// Composition.Section Recommendations Splice

// Patient History Section
Group: PatientHistory
Parent: Section
Description: "Patient History Section"
		Code = LOINC#34117-2										// is this correct code for section
		DomainResource substitute Observation						// Only Observations allowed in this section
		Section 0..0												// Child sections not allowed in this section
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject
		// Title = "Patient History"

// Findings Section
Group: Findings
Description: "Findings section"
Parent: Section
		Section
		includes FindingsLeftBreast 0..1							// Composition.Section Findings left breast Splice
		includes FindingsRightBreast 0..1							// Composition.Section Findings right  breast Splice
		Code = LOINC#34117-2										// is this correct code for section
		DomainResource 0..0											// Only two section children allowed from findings. No observations.
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject
//		[string] = "Findings"

// Findings left breast Section
// TODO: Each Findings should have
Group: FindingsLeftBreast
Parent: Section
Description: "Findings Left Breast Section"
Property: FindingSummaryBiRadCode 1..1								// Worst BiRad code in left breast findings
Property: BreastDensity 1..1										// Left breast density
//		Title[string] = "Findings Left Breast"
		Code = LOINC#26215-4 										// is this correct code for section
		DomainResource substitute Observation						// Only Observations allowed in this section
		Section 0..0												// Child sections not allowed in this section
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject

// Findings right breast Section
Group: FindingsRightBreast
Parent: Section
Description: "Findings Right Breast Section"
Property: FindingSummaryBiRadCode 1..1								// Worst BiRad code in right breast findings
Property: BreastDensity 1..1										// Right breast density
//		Title[string] = "Findings Right Breast"
		Code = LOINC#26216-2										// is this correct code for section
		DomainResource substitute Observation						// Only Observations allowed in this section
		Section 0..0												// Child sections not allowed in this section
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject

// Impressions Section
// TODO:add 
// - summary birads code (worst code)
// nest left and right findings under common findings.
Group: Impressions
Parent: Section
Description: "Clinical Impressions Section"
//		Title[string] = "Impressions"
		DomainResource substitute Condition							// Only Conditions allowed in this section
		Code = LOINC#19005-8										// is this correct code for section
		Section 0..0												// Child sections not allowed in this section
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject
			
// Recommendations Section
Group: Recommendations
Parent: Section
Description: "Recommendations Section"
//		Title[string] = "Recommendations"
		Code = LOINC#18783-1										// is this correct code for section
		Section 0..0												// Child sections not allowed in this section
		SortOrder 0..0												// No defined sort order
		FocalSubject 0..0											// Subject is always Composition.FocalSubject
		DomainResource substitute ActionRequest						// Only xxx request references allowed


// Summary bi rad code for a section.
Element: SummaryBiRadCode
Description: "BiRd code that summarizes a set of BiRad codes in a the document. Generally the most concerning/important BiRad code in the document."
Value: concept from BiRadCodeVs

// Summary bi rad code for a breast finding.
Element: FindingSummaryBiRadCode
Description: "BiRd code that summarizes a set of BiRad codes for a single breast finding. Generally the most concerning/important BiRad code in that finding."
Value: concept from BiRadCodeVs

// Breast density element.
Element: BreastDensity
Description: "Breast density value."
Value: concept from BreastDensityVs

// Technique used for observation.
Element: BreastExamTechnique
Description: "Technique used during breast examination."
Value: concept from DiagnosticTechniqueVs