Diagnostic Imaging Report - DICOM



Digital Imaging and Communications in Medicine (DICOM)Supplement 155: Imaging Reports using HL7 Clinical Document Architecture (revision and replacement of PS3.20)Prepared by:DICOM Standards Committee, Working Group 8: Structured Reportingin cooperation with Working Group 20: Integration of Imaging and Information Systems1300 N. 17th Street, Suite 1752Rosslyn, Virginia 22209 USAVERSION: Draft 2014-09-11Developed in accordance with: DICOM Workitem 2010-04-D Open issuesDo we need specific Conformance requirements in Part 2? Are the conformance requirements in Section 6 adequate?Consolidated CDA makes section.id mandatory, and Sup 155 follows that convention. Is this appropriate?Is it clear that Contrast Administration and Procedural Medications use the same template, but with different Business Names? Is this an appropriate specification mechanism?Radiology Recommendations was kept as a separate section within Impression to be able to label it as such. Is this necessary? PCPs interviewed said they want the emphasis as a teaching tool as well as just to highlight the recommendation so that they do not miss it. Specifically request professional review.Relationship to DICOM SR: Do we need a class of templates that is DICOM SR Content Item aware? Still Open. DICOM Part 20. CDA General Header: “Authenticator:- do we need to add Authenticator in the general header of the Imaging Report Template? In addition to Author and Legal Authenticator, where an Author could be a resident and the Legal Authenticator could be a radiologist. If so, what is the specific clinical use case?Use of Placer Order Numbers and Accession Numbers in inFulfillmentOf in header (section 8.2.3) – DICOM extensionto CDA markup defined for Accession Number to ensure it is easily found, and to distinguish from Placer Order Number which is primary id for Order. Is this appropriate/necessary?Sec 8.3: Should this implementation guide support the use case of addendum documents that are not replacements of the prior report?Sec 9.2: Clinical Information Section: Do we need more detailed entries for current medications / meds held prior to exam? More applicable to cardiology reports. Not as applicable to radiology perhaps. Cardiac CT? Specifically request professional review.Sec 9.8.5: Should we add a value set of typical complications, or important complications for quality purposes (extravasation, adverse reaction to contrast, death)Sec 9.8.6: OBUS Fetus Findings: Note that LOINC section code definition includes “by ultrasound” concept. Is this too limiting? Or is this the only practical OB modality? Specifically request professional review.Are methodCodes and other uses of CID 29 (acquisition modality) sufficiently defined to support multi-modality studies?Need summary radiation dose quantity codes – CID x10040Closed issuesArbitrary block of measurements from measurement app put into a CDA section. (D. Rubin) Resolution: just put into Findings, or into user-labeled subsectionTable of Contents TOC \o "1-3" \h \z \t "Title,1" Introduction to Supplement 155 PAGEREF _Toc398149589 \h 9DICOM and Reporting PAGEREF _Toc398149590 \h 9CDA and Implementation Guides PAGEREF _Toc398149591 \h 9Templates PAGEREF _Toc398149592 \h 10Imaging Report Templates for CDA PAGEREF _Toc398149593 \h 10Use with RSNA RadReport and IHE MRRT PAGEREF _Toc398149594 \h 11Structures provided by this Supplement PAGEREF _Toc398149595 \h 12Relationship to DICOM SR PAGEREF _Toc398149596 \h 12PS3.20 - Imaging Reports using HL7 Clinical Document Architecture PAGEREF _Toc398149597 \h 141Scope and Field of Application PAGEREF _Toc398149598 \h 152Normative and Informative References PAGEREF _Toc398149599 \h 163Definitions PAGEREF _Toc398149600 \h 193.1Codes and Controlled Terminology Definitions PAGEREF _Toc398149601 \h 194Symbols and Abbreviations PAGEREF _Toc398149602 \h 205Conventions PAGEREF _Toc398149603 \h 225.1Template metadata PAGEREF _Toc398149604 \h 225.1.1Template IDs and Version PAGEREF _Toc398149605 \h 225.1.2Open and Closed Templates PAGEREF _Toc398149606 \h 225.2Template Table Structure PAGEREF _Toc398149607 \h 235.2.1Business names PAGEREF _Toc398149608 \h 235.2.2Nesting level PAGEREF _Toc398149609 \h 245.2.3Element /Attribute Names and XPath Notation PAGEREF _Toc398149610 \h 245.2.4Cardinality PAGEREF _Toc398149611 \h 255.2.5Conformance Verbs PAGEREF _Toc398149612 \h 265.2.6Data Type PAGEREF _Toc398149613 \h 265.2.7Value / Vocabulary Conformance PAGEREF _Toc398149614 \h 265.2.8Invocation of Subsidiary Templates PAGEREF _Toc398149615 \h 285.2.9Additional Requirements PAGEREF _Toc398149616 \h 285.3Encoding PAGEREF _Toc398149617 \h 285.3.1translation PAGEREF _Toc398149618 \h 295.3.2Null Flavor PAGEREF _Toc398149619 \h 295.3.3Unknown Information PAGEREF _Toc398149620 \h 315.3.4XML ID and multiple element instantiations PAGEREF _Toc398149621 \h 325.4Extension and Namespace PAGEREF _Toc398149622 \h 336Conformance PAGEREF _Toc398149623 \h 346.1As a Creator Application PAGEREF _Toc398149624 \h 346.2As a Receiver Application PAGEREF _Toc398149625 \h 346.2.1Rendering Header Information for Human Presentation PAGEREF _Toc398149626 \h 346.3As a Document Instance PAGEREF _Toc398149627 \h 356.4As a Content Specification PAGEREF _Toc398149628 \h 357Document-Level Templates PAGEREF _Toc398149629 \h 367.1Imaging Report PAGEREF _Toc398149630 \h 367.1.1clinicalDocument/code PAGEREF _Toc398149631 \h 377.1.2Addendum PAGEREF _Toc398149632 \h 387.2Interventional Radiology Report (reserved) PAGEREF _Toc398149633 \h 387.3Anatomic Pathology Report (reserved) PAGEREF _Toc398149634 \h 388Header Content Modules PAGEREF _Toc398149635 \h 398.1General Header Elements PAGEREF _Toc398149636 \h 398.1.1effectiveTime PAGEREF _Toc398149637 \h 428.1.2setID and versionNumber PAGEREF _Toc398149638 \h 428.1.3recordTarget/patientRole and @ID PAGEREF _Toc398149639 \h 428.1.4recordTarget/patientRole/Patient/birthTime PAGEREF _Toc398149640 \h 438.1.5LegalAuthenticator PAGEREF _Toc398149641 \h 448.1.6InformationRecipient/intendedRecipient and @ID PAGEREF _Toc398149642 \h 458.1.7author/assignedAuthor and @ID (Person) PAGEREF _Toc398149643 \h 468.2Imaging Header Elements PAGEREF _Toc398149645 \h 468.2.1componentOf/encompassingEncounter PAGEREF _Toc398149646 \h 508.2.2Physician of Record Participant PAGEREF _Toc398149647 \h 508.2.3inFulfillmentOf/Order and @ID PAGEREF _Toc398149648 \h 518.2.4documentationOf/serviceEvent PAGEREF _Toc398149649 \h 528.3Parent Document Header Elements PAGEREF _Toc398149652 \h 558.3.1relatedDocument PAGEREF _Toc398149653 \h 568.3.2parentDocument/setId and versionNumber PAGEREF _Toc398149654 \h 569Section-Level Templates PAGEREF _Toc398149655 \h 579.1General requirements for sections PAGEREF _Toc398149656 \h 579.1.1section/text PAGEREF _Toc398149657 \h 579.1.2General Section Entries PAGEREF _Toc398149658 \h 609.1.3section/entry PAGEREF _Toc398149659 \h 619.2Clinical Information PAGEREF _Toc398149660 \h 629.3Imaging Procedure Description PAGEREF _Toc398149661 \h 639.3.1component/section Radiation Exposure and Protection Information PAGEREF _Toc398149662 \h 649.4Comparison Study PAGEREF _Toc398149663 \h 659.5Findings PAGEREF _Toc398149664 \h 669.5.1text PAGEREF _Toc398149665 \h 689.6Impression PAGEREF _Toc398149666 \h 689.7Addendum PAGEREF _Toc398149667 \h 709.7.1section/@ID PAGEREF _Toc398149668 \h 719.7.2author PAGEREF _Toc398149669 \h 719.7.3component/section - Communication of Actionable Findings PAGEREF _Toc398149670 \h 719.8Sub-sections PAGEREF _Toc398149671 \h 729.8.1Request PAGEREF _Toc398149672 \h 729.8.2Procedure Indications PAGEREF _Toc398149673 \h 739.8.3Medical (General) History PAGEREF _Toc398149674 \h 759.8.4Complications Section PAGEREF _Toc398149675 \h 769.8.5Radiation Exposure and Protection Information PAGEREF _Toc398149676 \h 789.8.6Key Images PAGEREF _Toc398149677 \h 829.8.7DICOM Object Catalog PAGEREF _Toc398149678 \h 849.8.8OBUS Fetus Findings PAGEREF _Toc398149679 \h 869.8.9Labeled Subsection PAGEREF _Toc398149680 \h 889.8.10Communication of Actionable Findings PAGEREF _Toc398149681 \h 909.8.11Recommendation PAGEREF _Toc398149682 \h 9310Entry-level Templates PAGEREF _Toc398149683 \h 9610.1Coded Observation PAGEREF _Toc398149684 \h 9610.1.1observation/@ID PAGEREF _Toc398149685 \h 9810.1.2code and @negationInd PAGEREF _Toc398149686 \h 9810.1.3text/reference and Related Narrative Block Markup PAGEREF _Toc398149687 \h 9910.1.4interpretationCode and translation PAGEREF _Toc398149688 \h 9910.1.5entryRelationship/@typeCode=SUBJ/observation - coded PAGEREF _Toc398149689 \h 9910.2Procedural Medication PAGEREF _Toc398149690 \h 9910.2.1Business Name alias PAGEREF _Toc398149691 \h 10110.2.2substanceAdministration/@ID PAGEREF _Toc398149692 \h 10110.2.3text/reference and Related Narrative Block Markup PAGEREF _Toc398149693 \h 10110.2.4doseQuantity PAGEREF _Toc398149694 \h 10110.3observationMedia PAGEREF _Toc398149695 \h 10210.3.1observationMedia/@ID and Related Narrative Block Markup PAGEREF _Toc398149696 \h 10310.3.2image and reference PAGEREF _Toc398149697 \h 10310.4Imaging Procedure Technique PAGEREF _Toc398149698 \h 10310.4.1id PAGEREF _Toc398149699 \h 10510.4.2code PAGEREF _Toc398149700 \h 10510.4.3methodCode - modality PAGEREF _Toc398149701 \h 10510.4.4methodCode – other parameters PAGEREF _Toc398149702 \h 10510.4.5targetSiteCode and laterality PAGEREF _Toc398149703 \h 10510.4.6text/reference and Related Narrative Block Markup PAGEREF _Toc398149704 \h 10510.4.7participation - location PAGEREF _Toc398149705 \h 10610.5Quantity Measurement PAGEREF _Toc398149706 \h 10610.5.1observation/@ID PAGEREF _Toc398149707 \h 10810.5.2text/reference and Related Narrative Block Markup PAGEREF _Toc398149708 \h 10810.5.3interpretationCode and translation PAGEREF _Toc398149709 \h 10810.6Study Act PAGEREF _Toc398149710 \h 10910.6.1act/@ID PAGEREF _Toc398149711 \h 11110.6.2entryRelationship/act - series PAGEREF _Toc398149712 \h 11110.7Series Act PAGEREF _Toc398149713 \h 11110.7.1act/@ID PAGEREF _Toc398149714 \h 11310.8SOP Instance Observation PAGEREF _Toc398149715 \h 11310.8.1observation/@ID PAGEREF _Toc398149716 \h 11610.8.2entryRelationship PAGEREF _Toc398149717 \h 11610.9Image Quality PAGEREF _Toc398149718 \h 11710.9.1text/reference and Related Narrative Block Markup PAGEREF _Toc398149719 \h 118ANNEX A —Additional Examples PAGEREF _Toc398149720 \h 119Names PAGEREF _Toc398149721 \h 119Addresses PAGEREF _Toc398149722 \h 119Time PAGEREF _Toc398149723 \h 120CD PAGEREF _Toc398149724 \h 120ANNEX B —Mapping DICOM SR to CDA PAGEREF _Toc398149725 \h 122PS3.6 – Data Dictionary PAGEREF _Toc398149726 \h 125ANNEX A —A Registry of DICOM Unique Identifiers (UIDs) (Normative) PAGEREF _Toc398149727 \h 126PS3.16 - Content Mapping Resource PAGEREF _Toc398149728 \h 127ANNEX B —DCMR Context Groups (Normative) PAGEREF _Toc398149729 \h 128CID 11?Route of Administration PAGEREF _Toc398149730 \h 128CID 25?Radiopharmaceuticals PAGEREF _Toc398149731 \h 128CID 29?Acquisition Modality PAGEREF _Toc398149732 \h 128CID 82 Units of Measurement PAGEREF _Toc398149733 \h 129CID 244 Laterality PAGEREF _Toc398149734 \h 129CID 4021?PET Radiopharmaceuticals PAGEREF _Toc398149735 \h 129CID 5000?Languages PAGEREF _Toc398149736 \h 130CID 6096 Pregnancy Status PAGEREF _Toc398149737 \h 130CID 7003?Diagnostic Imaging Report Purposes of Reference PAGEREF _Toc398149738 \h 131CID x7021? Imaging Report Document Titles PAGEREF _Toc398149739 \h 131CID x7035? Actionable Finding Classification PAGEREF _Toc398149740 \h 131CID x7036? Image Quality Assessment PAGEREF _Toc398149741 \h 132CID x10040? Summary Radiaion Exposure Quantities PAGEREF _Toc398149742 \h 132ANNEX D —DICOM Controlled Terminology Definitions (Normative) PAGEREF _Toc398149743 \h 133ANNEX N —Externally defined Value Sets PAGEREF _Toc398149744 \h 134ActPriority Value Set PAGEREF _Toc398149745 \h 134AdministrativeGender Value Set PAGEREF _Toc398149746 \h 135ImageMediaType Value Set PAGEREF _Toc398149747 \h 135NullFlavor Value Set PAGEREF _Toc398149748 \h 135ObservationInterpretation Value Set PAGEREF _Toc398149749 \h 136x_ BasicConfidentialityKind Value Set PAGEREF _Toc398149750 \h 136x_serviceEventPerformer Value Set PAGEREF _Toc398149751 \h 137Table of Figures TOC \c "Figure" Figure 1: XML document example PAGEREF _Toc395104095 \h 26Figure 2: Template element / and attribue example PAGEREF _Toc395104096 \h 26Figure 3: Translation code example PAGEREF _Toc395104097 \h 30Figure 4: nullFlavor example PAGEREF _Toc395104098 \h 30Figure 5: XML example of allowed nullFlavors when element is required PAGEREF _Toc395104099 \h 31Figure 6: Unknown medication example PAGEREF _Toc395104100 \h 32Figure 7: Unkown medication use of anticoagulant drug example PAGEREF _Toc395104101 \h 32Figure 8: No known medications example PAGEREF _Toc395104102 \h 33Figure 9: Example Business name based production logic for two measurements PAGEREF _Toc395104103 \h 33Figure 10: ClinicalDocument/code example PAGEREF _Toc395104104 \h 39Figure 11: use of the translation element to include local codes for document type PAGEREF _Toc395104105 \h 39Figure 12: header example PAGEREF _Toc395104106 \h 43Figure 13: recordTarget example PAGEREF _Toc395104107 \h 44Figure 14: legalAuthenticator example PAGEREF _Toc395104108 \h 45Figure 15: informationRecipient example PAGEREF _Toc395104109 \h 46Figure 16: Person author example PAGEREF _Toc395104110 \h 46Figure 17: Custodian example PAGEREF _Toc395104111 \h 47Figure 18: componentOf example PAGEREF _Toc395104112 \h 50Figure 19: Physician of record participant example PAGEREF _Toc395104113 \h 51Figure 20: inFulfillmentOf example – root and extension PAGEREF _Toc395104114 \h 52Figure 21: inFulfillmentOf example – placer number as UID PAGEREF _Toc395104115 \h 52Figure 22: documentationOf example PAGEREF _Toc395104116 \h 53Figure 23: Physician reading study performer example PAGEREF _Toc395104117 \h 54Figure 24: participant example PAGEREF _Toc395104118 \h 54Figure 25: dataEnterer example PAGEREF _Toc395104119 \h 55Figure 26: relatedDocument example PAGEREF _Toc395104120 \h 56Figure 27: WADO reference using linkHtml example PAGEREF _Toc395104121 \h 59Figure 28: Clinical Information section example PAGEREF _Toc395104122 \h 61Figure 29: Current Imaging Procedure description section example PAGEREF _Toc395104123 \h 63Figure 30: Comparison study section example PAGEREF _Toc395104124 \h 64Figure 31: Findings section example PAGEREF _Toc395104125 \h 66Figure 32: Impression section example PAGEREF _Toc395104126 \h 68Figure 33: Addendum section example PAGEREF _Toc395104127 \h 70Figure 34: Author example PAGEREF _Toc395104128 \h 71Figure 35: Request section example PAGEREF _Toc395104129 \h 73Figure 36: Procedure indications section example PAGEREF _Toc395104130 \h 74Figure 37: Medical (General) History section example PAGEREF _Toc395104131 \h 76Figure 38: Complications section example PAGEREF _Toc395104132 \h 77Figure 39: Radiation Exposure and Protection section example PAGEREF _Toc395104133 \h 82Figure 40: Key Images section example PAGEREF _Toc395104134 \h 84Figure 41: DICOM object catalog section example PAGEREF _Toc395104135 \h 86Figure 42: OBUS Fetus Findings section example PAGEREF _Toc395104136 \h 88Figure 43: Labeled sub-section example PAGEREF _Toc395104137 \h 90Figure 44: Communication of Actionable Results section example PAGEREF _Toc395104138 \h 93Figure 45: Radiology recommendation section example PAGEREF _Toc395104139 \h 95Figure 46: Coded observation example PAGEREF _Toc395104140 \h 99Figure 47: Procedural Medication activity example PAGEREF _Toc395104141 \h 101Figure 48: Procedure Technique template example PAGEREF _Toc395104142 \h 106Figure 49: Quantity measurement observation example PAGEREF _Toc395104143 \h 109Figure 50: Study act example PAGEREF _Toc395104144 \h 111Figure 51: Series act example PAGEREF _Toc395104145 \h 113Figure 52: Purpose of reference example PAGEREF _Toc395104146 \h 117Figure 53: SOP instance observation example PAGEREF _Toc395104147 \h 117Figure 54: Correct use of name example 1 PAGEREF _Toc395104148 \h 119Figure 55: Incorrect use of name example 1 - whitespace PAGEREF _Toc395104149 \h 119Figure 56: Incorrect use of Patient name example 2 - no tags PAGEREF _Toc395104150 \h 119Figure 57: Correct use telecom address example PAGEREF _Toc395104151 \h 119Figure 58: Correct use postal address example PAGEREF _Toc395104152 \h 119Figure 59: Correct use of IVL_TS example PAGEREF _Toc395104153 \h 120Figure 60: Correct use of TS with precision to minute example PAGEREF _Toc395104154 \h 120Figure 61: Correct use of TS with timezone offset example PAGEREF _Toc395104155 \h 120Figure 62: Incorrect use of IVL_TS example PAGEREF _Toc395104156 \h 120Figure 63: Incorrecet use of TS - insufficient precision example PAGEREF _Toc395104157 \h 120Figure 64: Incorrect use of TS when timezone offset required example PAGEREF _Toc395104158 \h 120Figure 65: Incorrrect use of timezone offset - not enough precision example PAGEREF _Toc395104159 \h 120Figure 66: Correct use of CD with no code - example PAGEREF _Toc395104160 \h 120Figure 67: Incorrect use of CD with no code - missing nullFlavor attribute example PAGEREF _Toc395104161 \h 121Introduction to Supplement 155This Supplement to the DICOM Standard introduces a new mechanism for specifying templates for imaging reports. Such reports are intended to be encoded using the HL7 Clinical Document Architecture Release 2 (CDAr2, or simply CDA) Standard.The nature of radiology reporting is evolving from purely text based reports to incorporate more discrete data elements (measurements, categorical findings, etc.). It is the purpose of this Supplement to support current and evolving practice. This Supplement therefore focuses on primarily narrative text reports, but also supports incorporation of discrete data and image references. It is envisioned that this Supplement is just the first step in DICOM specification of imaging report templates for CDA. Its scope is therefore limited primarily to radiology diagnostic imaging (including screening exams), and some interventional radiology and cardiology (where clinicans may deem the templates appropriate). Future work may include in scope anatomic pathology or other imaging procedures, as well as templates with more required discrete data element content.DICOM and ReportingReporting has been a significant part of the DICOM standards development program since work on Supplement 23: Structured Reporting began in 1995. That Supplement defined a report encoding based on the classical DICOM attributes and data elements specified in DICOM Part 5, with templates specified in Part 16. There was substantial discussion during the development of Supplement 23 as to whether reports should be encoded using XML, at that time not yet a widely deployed technology.While DICOM Structured Reporting has an established place in the encoding of image analysis results, or “evidence documents”, it has seen only limited use for clinical reports. The clinical report production and distribution environment has not been amenable to the use of classical DICOM object and data element encoding.The DICOM Standards Committee in 2010 decided to approve a Work Item for an approach to reporting based on CDA, an XML document format specified by HL7. The DICOM Standards Committee, as the premier worldwide collaboration between imaging-related professional societies and the imaging industry, was agreed as the appropriate organization to produce CDA Implementation Guides and Templates for specific clinical imaging use cases.CDA and Implementation GuidesThe HL7 Clinical Document Architecture has emerged as the industry consensus standard for the formatting of clinical reports across all medical disciplines. DICOM currently provides for both encapsulation of CDA documents within DICOM SOP Instances, and for direct reference to native (unencapsulated) CDA document instances (equivalent to direct reference of DICOM SOP Instances). Native and encapsulated CDA documents may be managed on DICOM exchange media through the DICOMDIR Basic Directory Information Object.The generic CDA format is typically constrained for specific document types by implementation guides in support of specific use cases. Two such implementation guides are the Basic Diagnostic Imaging Report, published as an informative HL7 specification and based on DICOM Structured Reporting Templates 2000 and 2005, and Procedure Notes, published as an HL7 Draft Standard for Trial Use and applicable to interventional imaging procedures (interventional radiology, endoscopy, cardiology). Both of these implementation guides were developed with participation from DICOM WG-20 / HL7 Imaging Integration Work Group. Those two guides were subsequently adapted for use under the US Meaningful Use of Electronic Health Records incentive program, and the adaptation was published in the Consolidated CDA Implementation Guide - US Realm (C-CDA).There are actually multiple layers of constraint and implementation guidance that go into a CDA imaging report. First, CDA itself is a constraint (a Refined Message Information Model, or RMIM) applied to the HL7 v3 Reference Information Model (v3 RIM) and Implementation Technology Specification for XML (v3 XMLITS). This Supplement defines several report document structures that further constrain CDA through defined or required header elements, sections, and structured entries. Further, professional societies or healthcare providers may define even more detailed constraints and guidance for use in reporting on specific sub-specialty procedures.TemplatesThe constraints specified in implementation guides take the form of templates. Templates are formally described patterns that specify the structure and content of a document (or a portion thereof). Structure includes the relationships among portions of the document; content includes concepts and vocabularies used for a particular application. Templates may impose mandatory constraints on structure and content (e.g., minimum data sets), and/or may specify recommended or optional features. Templates have several purposes: They improve interoperability by limiting the variability of unconstrained (idiosyncratic or arbitrary) structures and content. The specificaion of templates allows a professional society or healthcare provider to normalize best practice for reports with content appropriate for their use cases, including foreseeable secondary uses such as research or quality improvement. A template may be used operationally in the creation of reports; an application may use the template to guide authoring of the report, ensuring the entry or composition of essential reporting elements, and structuring that data into the target encoded format. Ultimately, templates provide a conformance validation for instances of reports against the purposes (use case) of the template. Imaging Report Templates for CDA72390016510000This Supplement defines the CDA format structures and technical constraints, i.e., templates, for documents, sections, and entries to be used in imaging report instances. These report instance templates are thus a set of conformance criteria for such report instances.However, these templates may also be viewed as providing high level structures that can hide the details of implementation. For example, by defining a Findings document section or an Impression section, users can discuss the content of those sections without needing to know how it is represented in the CDA instance. For this purpose, the Supplement specifies a public implementation-independent specification, denoted business names, for each variable element; this allows applications to to deal with abstract report constructs (such as sections or entries) and their logical data content.This standard therefore also has the goal of facilitating, through these public interfaces, the creation of report authoring templates by professional societies or healthcare providers for use in reporting on imaging procedures. The templates defined in this Supplement provide canonical documentation categories (e.g., sections, numerical measurements, categorical observations, etc.) that map into specific CDA structures. It specifies names of data element “slots” that may be used to link data collected by the report authoring application into the CDA structural templates of this Implementation Guide. Each name is specified with the type of data elements that will populate the CDA. A similar concept is utilized by the HL7 greenCDA informative specification.98742543053000Figure - Process flow using CDA Report Templates, MRRT, and RSNA TemplatesUse with RSNA RadReport and IHE MRRT This work is complementary to and coordinated with the RSNA Radiology Reporting (RadReport) initiative and the IHE Management of Radiology Report Templates (MRRT) Profile. RadReport is focused on developing best practice clinical content templates for authoring radiology reports; MRRT specifies an XML-based encoding for those report authoring templates that can be used by a report authoring application.RadReport and MRRT thus provide a standardized platform for the front end authoring of a report; this Supplement specifies the back end encoding of that report content into CDA structures. These are independent activities – the RadReport and MRRT authored content could be encoded into a simple text or PDF document, rather than CDA, and mechainsms other than RadReport and MRRT could provide the content authoring for CDA imaging reports conformant to the templates defined in this Supplement.Structures provided by this SupplementCDA documents include a header and a body. The header is fully structured data that allows management and exchange of clinical documents by generic document handling systems and interfaces, e.g., as specified in the IHE Cross-Enterprise Document Sharing (XDS) Profile. This Supplement specifies templates for header elements of particular interest for imaging reports, such as the order and the service event and performer.For the CDA body, the principal structures provided by this Supplement are the narrative sections for reports. The RSNA RadReport initiative has specified five canonical top level narrative sections, which are supported by specific templates: Procedure Description, Clinical Information, Comparison Study, Findings, and Impression. This Supplement also specifies predefined subsections for some of those primary sections, e.g., Radiation Exposure within the Procedure Description section. Each section may also have defined Structured Entries (discrete data elements), usually optional in the context of a primarily narrative radiology report.This Supplement also allows user-titled subsections that might be used for a particular reporting focus, e.g., “Liver” or “Tumor 1” within Findings. Note that while the subsection title may impart informal scoping semantics to the human-readable narrative block (i.e., the title “Liver” implies that all the narrative text is about the liver), there is no formal semantic post-coordination of the title with the concept code of a structured entry in that subsection (a measurement of “length” cannot be formally inferred to mean “length of liver”). This is deemed to be acceptable for the first generation of reports produced under this Supplement, and is a potential area for future development.One exception to this non-semantic subsection user titles is for subsections in obstetric ultrasound reports whose theme is “Fetus”, or “Fetus n”.? LOINC specifies a section code and CDA explicitly defines a Subject section participation that formally convey scoping context to the content of that subsection. The OBUS (obstetric ultrasound) Fetus Findings has explicitly modeled the use of Subject participation for fetus.Relationship to DICOM SRA key requirement for radiology reporting, especially in areas such as ultrasound, is to incorporate observations (e.g., measurements) recorded in DICOM Structured Report instances. It is highly desirable to also include any references to the primary evidence, e.g., links to imags and regions of interest, that are recorded in the SR. Previous related work, as standardized in DICOM Part 20, provides a mechanism for transcoding DICOM SR observations into CDA entries. However, it assumed that the CDA report formatting process is an application aware of DICOM SR constructs, and could preserve such measurements or observations with full fidelity into the clinical report. However, this Supplement does not assume that the report formatting process has any cognizance of SR. While there is a need to import observations (measurements, assessments) from SR evidence documents into the CDA format final report, this Supplement assumes an indirect method of such data import. The report authoring process, and any associated report authoring templates, are responsible for identifying SR content to be included in the report, thus allowing the clinician to review those observations in the context of the report narrative, and to modify or exclude any of those SR observations. This Supplement provides CDA structures for coded/numeric observations whose ultimate source may or may not be a DICOM SR observation.PS3.20 - Imaging Reports using HL7 Clinical Document ArchitectureScope and Field of ApplicationThis part of the DICOM Standard specifies templates for the encoding of imaging reports using the HL7 Clinical Document Architecture Release 2 (CDAr2, or simply CDA) Standard. Within this scope are clinical procedure reports for all specialties that use imaging for screening, diagnostic, or therapeutic purposes.This Part constitutes an implementation guide for CDA, and is harmonized with the approach to standardized templates for CDA implementation guides developed by HL7.It provides “business names” for data elements that link data in user terminology, e.g., collected by a report authoring application, to specific CDA encoded elements.As an implementation guide for imaging reports, particular attention is given to the use and reference of data collected in imaging procedures as explicit evidence within reports.This data includes images, waveforms, measurements, annotations, and other analytic results managed as DICOM SOP Instances. Specifically, the Part inclues a specification for transformation of certain DICOM Structured Report instances into CDA documents.Normative and Informative ReferencesThe following standards contain provisions that, through reference in this text, constitute provisions of this Standard. At the time of publication, the editions indicated were valid. All standards are subject to revision, and parties to agreements based on this Standard are encouraged to investigate the possibilities of applying the most recent editions of the standards indicated below.ISO/IEC Directives, Part 2ISO/IEC Directives, Part 2 - Rules for the structure and drafting of International Standards - Sixth edition, 2011ANSI/HL7 CDA?, R2-2005HL7 Version 3 Standard: Clinical Document Architecture (CDA) Release 2, 2005.CDA? is a registered trademark of HL7 International.ANSI/HL7 V3 CPPV3MODELS, R1-2012HL7 Version 3 Standard: Core Principles and Properties of Version 3 Models, Release 1ANSI/HL7 V3 CMET, R2-2009Health Level Seven Version 3 Standard: Common Message Element Types, Release 2, 2009.ANSI/HL7 V3 DT, R1-2004HL7 Version 3 Data Types Abstract Specification, Release 1 – November 2004. [Note: this specific release version is required by CDA R2]ANSI/HL7 V3 XMLITSDT, R1-2004HL7 Version 3 XML Implementation Technology Specification - Data Types, Release 1 – April 2004. [Note: this specific release version is required by CDA R2]HL7 CDA R2 DIR IG, R1-2009Health Level Seven Implementation Guide for CDA Release 2: Imaging Integration, Basic Imaging Reports in CDA and DICOM, Diagnostic Imaging Reports (DIR) Release 1.0 – Informative, 2009.HL7 CDAR2_IG_IHE_CONSOL HL7 Implementation Guide for CDA? Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm, Draft Standard for Trial Use, July 2012 ()HL7 CDAR2_IG_GREENMOD4CCD HL7 Implementation Guides for CDA? R2: greenCDA Modules for CCD?, Release 1 – Informative, April 2011 ()HL7 v3-2014HL7 Version 3 Interoperability Standards, Normative Edition 2014 (] IHE Card Sup CIRC IHE Cardiology Technical Framework Supplement, Cardiac Imaging Report Content, Trial Implementation, July 2011 () IHE ITI TFIHE IT Infrastructure Technical Framework, Revision 10.0, September 2013 () IHE PCC TFIHE Patient Care Coordination Technical Framework, Revision 9.0, October 2013 () IHE RAD TFIHE Radiology Technical Framework, Revision 13.0, July 2014 () LOINC Logical Observation Identifier Names and Codes, Regenstrief Institute, Indianapolis 2013.This product includes all or a portion of the LOINC? table, LOINC panels and forms file, LOINC document ontology file, and/or LOINC hierarchies file, or is derived from one or more of the foregoing, subject to a license from Regenstrief Institute, Inc. Your use of the LOINC table, LOINC codes, LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file also is subject to this license, a copy of which is available at?. The current complete LOINC table, LOINC Users' Guide, LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file are available for download at?. The LOINC table and LOINC codes are copyright ? 1995-2013, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. The LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file are copyright ? 1995-2013, Regenstrief Institute, Inc. All rights reserved. THE LOINC TABLE (IN ALL FORMATS), LOINC PANELS AND FORMS FILE, LOINC DOCUMENT ONTOLOGY FILE, AND LOINC HIERARCHIES ARE PROVIDED "AS IS."? ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. LOINC? is a registered United States trademark of Regenstrief Institute, Inc. A small portion of the LOINC table may include content (e.g., survey instruments) that is subject to copyrights owned by third parties. Such content has been mapped to LOINC terms under applicable copyright and terms of use. Notice of such third party copyright and license terms would need to be included if such content is included.RFC 4646 Tags for Identifying Languages, The Internet Society, 2005SNOMED CT? Systematized Nomenclature of Medicine - Clinical Terms, International Release, International Health Terminology Standards Development Organisation (IHTSDO), January 2013SNOMED CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).UCUM Unified Code for Units of Measure, Regenstrief Institute, Indianapolis 2013.This product includes all or a portion of the UCUM table, UCUM codes, and UCUM definitions or is derived from it, subject to a license from Regenstrief Institute, Inc. and The UCUM Organization. Your use of the UCUM table, UCUM codes, UCUM definitions also is subject to this license, a copy of which is available at . The current complete UCUM table, UCUM Specification are available for download at . The UCUM table and UCUM codes are copyright ? 1995-2013, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved.THE UCUM TABLE (IN ALL FORMATS), UCUM DEFINITIONS, AND SPECIFICATION ARE PROVIDED "AS IS." ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.XML Extensible Markup Language (XML) 1.0 (Fifth Edition), World Wide Web Consortium, 2008 () XML Schema DatatypesXML Schema Part 2: Datatypes Second Edition, World Wide Web Consortium, 2004 () xml:idxml:id Version 1.0, World Wide Web Consortium, 2005 () XPathXML Path Language (XPath), Version 1.0, World Wide Web Consortium, 1999 () DefinitionsFor the purposes of this Standard the following definitions apply.Codes and Controlled Terminology DefinitionsThe following terms used in this Part of the DICOM Standard are defined in PS3.16:Context GroupA set of coded concepts defined by a Mapping Resource forming a set appropriate to use in a particular context.Context ID (CID)Identifier of a Context Group.TemplateA pattern that describes the Content Items, Value Types, Relationship Types and Value Sets that may be used in part of a Structured Report content tree, or in other Content Item constructs, such as Acquisition Context or Protocol Context. Analogous to a Module of an Information Object Definition.Template ID (TID)Identifier of a Template.Coding SchemesDictionaries (lexicons) of concepts (terms) with assigned codes and well defined meanings.Symbols and AbbreviationsThe following symbols and abbreviations are used in this Part of the Standard.ANSIAmerican National Standards InstituteCDAClinical Document Architecture (HL7)DICOMDigital Imaging and Communications in MedicineHL7Health Level 7HMDHierarchical Message Description (HL7)IHEIntegrating the Healthcare EnterpriseIODInformation Object DefinitionISOInternational Standards OrganizationLOINCLogical Observation Identifiers Names and CodesMRRTIHE Management of Radiology Report Templates ProfileNEMANational Electrical Manufacturers AssociationOIDObject Identifier (ISO 8824)SNOMEDSystematized Nomenclature of MedicineSRStructured ReportingUCUMUnified Code for Units of MeasureUIDUnique IdentifierXMLExtensible Markup LanguageADPostal Address (HL7 v3 Data Type)CECoded With Equivalents (HL7 v3 Data Type)CDConcept Descriptor (HL7 v3 Data Type)CSCoded Simple Value (HL7 v3 Data Type)EDEncapsulated Data (HL7 v3 Data Type)ENEntity Name (HL7 v3 Data Type)IIInstance Identifier (HL7 v3 Data Type)INT Integer Number (HL7 v3 Data Type)IVL<>Interval (HL7 v3 Data Type)LIST<>List (HL7 v3 Data Type)OIDISO Object Identifier (HL7 v3 Data Type)ONOrganization Name (HL7 v3 Data Type)PNPerson Name (HL7 v3 Data Type)PQPhysical Quantity (HL7 v3 Data Type)STCharacter String (HL7 v3 Data Type)TELTelecommunication Address (HL7 v3 Data Type)TSPoint in Time (HL7 v3 Data Type)UIDUnique Identifier String (HL7 v3 Data Type)URLUniversal Resource Identifier (HL7 v3 Data Type)ConventionsTemplate metadataEach template has a set of metadata, as specified in the HL7 Templates Specification. The metadata is presented as a table, as shown below.Template ID OIDNameEffective DateVersion LabelStatus“draft”, “active”, “review” or “retired”Description Classificationtype of the template, e.g. CDA Section LevelRelationships relationships to other templates or model artifactsContextOpen/ClosedRevision HistoryTemplate IDs and VersionTemplate identifiers (templateId) are assigned at the document, section, and entry level. When valued in an instance, the template identifier signals the imposition of a set of template-defined constraints. The value of this attribute (e.g., @root="2.16.840.1.113883.10.20.22.4.8") provides a unique identifier for the template in question.A template may be further qualified by a version label. This label may be used as the extension attribute of the templateId (e.g., @extension="20150309"). Note that the version label is typically not used as a conformance constraint, to allow both creators and recivers to adapt to evolution in the templates.Within this Standard, template versions are identified by the string “DICOM” and the date adoption, separated by a hyphen (e.g., DICOM-20150523).Open and Closed TemplatesIn open templates, all of the features of the CDA Specification are allowed except as constrained by the templates. By contrast, a closed template specifies everything that is allowed and nothing further may be included.If a template is a specialization of another template, its first constraint indicates the more general template. The general template is not always required. In all cases where a more specific template conforms to a more general template, asserting the more specific template also implies conformance to the more general template. Template Table StructureEach template is specified in tabular form, as shown below.Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValueSubsidiary TemplateScopingBusinessName ElementBusinessNameReferencedBusinessNameBusiness namesThis Part uses “business names” to more easily and consistently identify and map common data elements from imaging reports into the proper context-specific CDA/XML structure.A business name is assigned to each element or attribute that may have a value assigned in the production of the document instance. Business names are specified to facilitate the implementation of production logic for report authoring applications. The benefit is that developers of report authoring applications are not required to have an in depth knowledge of CDA, the HL7 v3 R-MIM data model, or the xml structures. The use of readable and intuitive business names provides a method of direct access to insert data that is specific to each report instance. Note:“Business names” are also described in the greenCDA specification, but that specification implies the use of a specific XML structure for production logic that is not intended by this Part.In this guide, the business names are represented in camelCase (alternating upper and lower case, no spaces) in the Business Name column of the template tables. Business names are hierarchically organized, and contextually scoped by higher level business names. Data element/attribute level business names are shown in normal font, while business names that provide scoping for data elements are shown in bold font. Referenced business names from included templates are shown in italic (see section 5.2.9)Examples:The top level scoping business name is “ImagingReport”The business name for the text element of the Clinical Information report section is “ImagingReport:ClinicalInformation:Text”The business name for the text element of the Impression section is “ImagingReport:Impression:Text”Note that both Clinical Information and Impression define a business name “Text”, but these are distinguished by their hierarchical location under scoping business names. The use of business names or the specification of such production logic is outside the scope of this Standard.Nesting levelCDA documents are encoded using the Extensible Markup Language (XML), and are marked up through hierarchically nested XML elements (tags). The Nesting Level column of the template tables identifies the hierarchical level of each element relative to the other elements in the table using the character right angle bracket ‘>’.XML elements may have attributes, encoded as name=value pairs within the element tag. Such attributes are identified using the character at sign ‘@’.Element /Attribute Names and XPath Notation The name of each XML element and attribute used in a CDA document for which specific constraints are applied is shown in the Element/Attribute column of the template tables. Elements and attributes that use the default value specified in CDA Specification are not shown. For example, the Section element has default attributes classCode='DOCSECT' and moodCode='EVN'; these are not listed in the templates.XML Path Language (XPath) notation is used in this Standard to identify the XML elements and attributes within the CDA document instance to which various constraints are applied. The implicit context of these expressions is the root of the document. This notation provides a mechanism that will be familiar to developers for identifying parts of an XML document.Xpath statements appear in this Part in a monospace font.XPath syntax selects nodes from an XML document using a path containing the context of the node(s). The path is constructed from node names and attribute names (prefixed by a ‘@’) and catenated with a ‘/’ symbol. Following is an example of a fragment of a CDA document.Figure SEQ Figure \* ARABIC 1: XML document example<author><assignedAuthor>...<code codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' code='17561000' displayName='Cardiologist' />...</assignedAuthor></author>Following is an example of a fragment of a template specification table.Figure SEQ Figure \* ARABIC 2: Template element / and attribue example…Nest LevelElement/ Attribute…author> assignedAuthor…>> code>>@ @code…In the above example, the code attribute of the code element could be selected with the XPath expression author/assignedAuthor/code/@code.Cardinality The cardinality indicator (0..1, 1..1, 1..*, etc.) specifies the allowable occurrences within a document instance. The cardinality indicators are interpreted with the following format “m…n” where m represents the least and n the most:0..1 zero or one 1..1 exactly one1..* at least one 0..* zero or more1..n at least one and not more than nThe terms optional and required describe the lower bound of cardinality as follows:Optional means that the number of allowable occurances of an element may be 0; the cardinality will be expressed as [0..1] or [0..*] or similar. In these cases, the element may not be present in the instance.Required means that the number of allowable occurances of an element must be at least 1; the cardinality will be expressed as [m..n] where m >=1 and n >=1, for example [1..1] or [1..*].. In these cases, the element must be present in the instance. If an element is required, but is not known (and would otherwise be omitted if it were optional), it must be be represented by a nullFlavor. Conformance Verbs Each element / attribute has a conformance verb (keyword) in addition to the cardinality constraint.The keywords shall, should, may, should not, shall not, and NEED not in this document are to be interpreted as described in ISO/IEC Directives, Part 2, Annex H “Verbal forms for the expression of provisions”:shall: an absolute requirementshall not: an absolute prohibition against inclusionshould/should not: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different coursemay/NEED NOT: truly optional; can be included or omitted as the author decides with no implications The keyword "shall" allows the use of nullFlavor unless the requirement is on an attribute or the use of nullFlavor is explicitly precluded (see section 5.2.7.1 Value / Vocabulary Conformance Terms and section 5.3.2 Null Flavor).Within the template, the keyword COND (conditional) may be present. In this case, the specification of the condition, and the conformance verbs associated with the condition being true or false, are described below the table in a paragraph flagged with the COND keyword.In an open template, additional elements and attributes allowed by the CDA Specification are not precluded by template constraints, unless there are applicable shall not template specifications.Data TypeThe data type associated with each element / attribute is specified, as described in the CDA Specification and its referenced HL7v3 Data Types Release 1.Many data types are non-primitive, and may specify constituent component elements and/or attributes. Such subsidiary components are specified in the templates if specific constraints are to be applied to them.Value / Vocabulary Conformance The template table may specify specific values or vocabularies to be used with an element or attribute. The constraint may be to a single fixed value, to a Value Set from which the value is to be drawn, to a named Concept Domain, or to a mapping from a DICOM SOP Instance.Value / Vocabulary Conformance TermsValue constraints include a conformance verb (shall, should, may, etc.) as defined in Conformance Verbs. Elements for which nullFlavor is forbidden are indicated with a constraint noNull.Additionally, constraints specifying Value Sets include a coding strength conformance CWE (Coded With Extensibility) or CNE (Coded with No Extensibility), as defined in Core Principles and Properties of HL7 Version 3 Models, Release 1. Further, Value Set constraints may include an indication of dynamic vs. static binding. Value-set constraints can be static, meaning that they are bound to a specified version of a Value Set, or dynamic, meaning that they are bound to the most current version of the Value Set. By default, Value Sets have dynamic binding, unless explicitly specified with static binding.Coded Simple ValueValues of Data Type CS (Coded Simple Value) have a fixed code system defined in the CDA Specification, and are simple strings. The template tables identify only the constraint on the code value, and do not specify that fixed code system nor the code meaning (display name).Concept DescriptorSingle values of Data Type CD (Concept Descriptor) or CE (Coded With Equivalents) are specified in the template tables with the triplet notation specified in PS3.16:(CodeValue, Coding Scheme Designator, "Code Meaning")The Coding Scheme Designator is a simple human readable identifier of the code system, and corresponds to the optional codeSystemName attribute of the CD or CE element. The CDA Specification requires the Code System OID to be encoded in an attribute of the CD or CE element. The corresponding OID for each Coding Scheme Designator is provided in the PS3.16 Section titled “Coding Schemes”. The Code Meaning is encoded in the displayName attribute of the CD or CE element. Concept DomainsAs defined in Core Principles and Properties of HL7 Version 3 Models, “A Concept Domain is a named category of like concepts (a semantic type) that is specified in the vocabulary declaration of an attribute in a information model… Concept Domains exist to constrain the intent of the coded element while deferring the binding of the element to a specific set of codes until later in the specification …process.” In this Standard, Concept Domains are used to provide a named category in a structural template that can be bound to a specific value or value set by an invoking template, thus specializing the structural template for a particular use case. For example, the Quantity Measurement template “observationType” Concept Domain can be bound to a value set of fetal ultrasound measurements in one invoking template, or to a value set of cardiac CT measurements in another invoking template.Concept Domain names are similar to element Business Names in that they provide a public interface that is bound to specific values later in the document specification and production process.Mapping from DICOM SOP InstancesElements whose value is intended to be mapped from a DICOM SOP Instance will have the source attribute name and tag identified in the Value column in italic font.Invocation of Subsidiary TemplatesA template may invoke (include) subsidiary templates. Templates typically have one of two styles, a single parent element with child element structure, or a flat list of sibling elements.The single parent element style is typical for the top level Document, Section, and Entry templates, and the parent element is of the HL7 v3 RIM act class. Invocation of such a template therefore involves an actRelationship element; that actRelationship element is specified in the invoking template.The flat list style is typical for sets of elements and attributes aggregated for editorial convenience.Invocation of a subsidiary template includes the name of invoked template and its templateID, specified in the Subsidiary Template column of the invoking template table. For an invoked template of the single parent element style, the scoping business name and top level element are provided in italics in the invoking template table. This indicates this is data copied from the specification in invoked template for the reader’s convenience.Vocabulary Binding And ConstraintsA template invocation may provide vocabulary Concept Domain binding or other vocabulary constraints, e.g., limiting an element in the invoked template to a specific value from its defined Value Set. These vocabulary constraints are specified in tabular form, as shown below. Concept Domain or ElementBindingAdditional RequirementsEach template may be accompanied by additional requirements and usage explanations in narrative specification language.EncodingA full discussion of the representation of data types and vocabulary is outside the scope of this document; for more information, see the HL7 V3 specifications on Abstract Data Types R1 and XML Data Types R1 referenced in the CDA Specification.Notes:1. Many Data Types encode their values in attributes, rather than character data. For example, the URL Data Type encodes its value in the value attribute within the element tag, e.g., <reference value="">. Within this specification, the attribute(s) that hold the value are not identified, except where specific constraints apply.2. The Consolidated CDA specification includes extensive examples of valid and invalid encodings.3. The specification of a representation of Data Types for use in business name-based report production logic is outside the scope of this Standard.translationData Type CD (Concept Descriptor) and CE (Coded With Equivalents) allow a translation code element, which allows the encoding of the same concept in an alternate coding system. This supports the encoding of both an originally entered (local) code, and a code specified for cross-system interoperability.There is a discrepancy in the use of translation code versus the root code between HL7 Data Types R1 and this Standard. The Data Types R1 formally specifies the original code (as initially entered in an information system application) in the root. This Standard follows the convention used in the Consolidated CDA Implementation Guide specification, which specifies the standard interoperable code in the root, whether it is original or a translation. Note:This discrepancy is resolved in HL7 Data Types R2 to follow the convention used here, but CDA uses Data Types R1.Figure SEQ Figure \* ARABIC 3: Translation code example<code code='206525008’ displayName='neonatal necrotizing enterocolitis' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'> <translation code='NEC-1' displayName='necrotizing enterocolitis' codeSystem='2.16.840.1.113883.19'/></code>Null Flavor Information technology solutions store and manage data, but sometimes data are not available: an item may be unknown, not relevant, or not computable or measureable. In HL7 v3, a flavor of null, or nullFlavor, describes the reason for missing data.?For example, if a patient arrives at an Emergency Department unconscious and with no identification, a null flavor is used to represent the lack of information. The patient’s birth date would be represented with a null flavor of “NAV”, which is the code for “temporarily unavailable”. When the patient regains consciousness or a relative arrives, we expect to know the patient’s birth date.Figure SEQ Figure \* ARABIC 4: nullFlavor example<birthTime nullFlavor="NAV"/> <!--coding an unknown birthdate-->Use null flavors for unknown, required, or optional attributes: NI No information. This is the most general and default null flavor.NA Not applicable. Known to have no proper value (e.g., last menstrual period for a male).UNK Unknown. A proper value is applicable, but is not known.ASKU Asked, but not known. Information was sought, but not found (e.g., the patient was asked but did not know).NAV Temporarily unavailable. The information is not available, but is expected to be available later.NASK Not asked. The patient was not asked.MSKThere is information on this item available but it has not been provided by the sender due to security, privacy, or other reasons. There may be an alternate mechanism for gaining access to this information.This above list contains those null flavors that are commonly used in clinical documents. For the full list and descriptions, see the nullFlavor vocabulary domain in the v3 Vocabulary referenced by the CDA specification. Any SHALL conformance requirement on an element may use nullFlavor, unless nullFlavor is explicitly disallowed (as indicated by noNull, see Section 5.2.7.1 Value / Vocabulary Conformance Terms). SHOULD and MAY conformance requirement may also use nullFlavor. nullFlavor does not apply to conformance requirements on attributes. The encoding of nullFlavor as an attribute of the data type element is not shown in the templates, hence there is no business name associated with the attribute. Note:Production logic based on business names needs to provide a mechanism for assignment of a value to the nullFlavor attribute as an alternative for a value for the element. Specification of such production logic is outside the scope of this Standard.Figure SEQ Figure \* ARABIC 5: XML example of allowed nullFlavors when element is required<entry> <observation classCode="OBS" moodCode="EVN"> <id nullFlavor="NI"/> <code nullFlavor="OTH"> <originalText>New Grading system</originalText> </code> <statusCode code="completed"/> <effectiveTime nullFlavor="UNK"/> <value xsi:type="CD" nullFlavor="NAV"> <originalText>Spiculated mass grade 5</originalText> </value> </observation></entry>Unknown InformationIf a document creator wants to state that a piece of information is unknown, the following principles apply:1.If the creator doesn’t know an attribute of an act, that attribute can be null.Figure SEQ Figure \* ARABIC 6: Unknown medication example<text>patient was given a medication but I do not know what it was</text><entry> <substanceAdministration moodCode="EVN" classCode="SBADM"> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code nullFlavor="NI"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>2.If the creator doesn’t know if an act occurred, the nullFlavor is on the act (detail could include specific allergy, drug, etc.).Figure SEQ Figure \* ARABIC 7: Unkown medication use of anticoagulant drug example<text>I do not know whether or not patient received an anticoagulant drug</text><entry> <substanceAdministration moodCode="EVN" classCode="SBADM" nullFlavor="NI"> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code code="81839001" displayName="anticoagulant drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>3. If the sender wants to state ‘no known’, a negationInd can be used on the corresponding act (substanceAdministration, Procedure, etc.)Figure SEQ Figure \* ARABIC 8: No known medications example<text>No known medications</text><entry> <substanceAdministration moodCode="EVN" classCode="SBADM" negationInd=”true”> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code code="410942007" displayName="drug or medication" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>Other implementation guides recommended using specific codes to assert no known content, for example SNOMED CT 160244002 "No known allergies" or 160245001 "No current problems or disability". Specific codes are still allowed; however, use of negationInd is an alternative.XML ID and multiple element instantiationsThe XML Specification allows each markup tag to have an attribute of type ID, whose value is unique within the document, that allows reference to that markup. The CDA schema defines such attributes with attribute name ID.Notes:1. Thus the attribute named ID is of XML attribute type ID. This must further be distinguished from the element named id of HL7v3 Data Type UID that is part of most RIM classes. The attribute name is always upper case, the element name is always lower case.2. The actual CDA schema specification uses the XML Schema Datatypes definition of XML ID (xs:ID). Readers may also be familiar with the xml:id specification, which is not formally used by CDA as it was published after the CDA specification.In the CDA R2 Specification and this Implementation Guide, the XML ID attribute capability is used to provide linkage between structured entries and the corresponding narrative text, and more generally to marked-up content (see section 9.1.1 Text).In this Implementation Guide, the ID attribute is required for template elements that may have multiple instantiations in the same document; e.g., each instantiation of the Coded Observation element would have a (locally) unique XML ID attribute (and would also have a globally unique id element of HL7 type UID). Each instantiation has its own unique XML ID, which is used as a discriminator between those multiple instantiations. This allows business name based logic for authoring applications to identify specific instances of an element.As a convention, the business name for each element that may nave multiple instantiations has a suffix [*], indicating the use of the XML ID attribute as a discriminator.Figure SEQ Figure \* ARABIC 9: Example Business name based production logic for two measurements -- instantiate two measurementsnew ImagingReport:Findings:QuantityMeasurement[Q21a] -- "Q21a" is the XML IDnew ImagingReport:Findings:QuantityMeasurement[Q21b] -- "Q21b" is the XML ID-- set value for first measurementsetcontext ImagingReport:Findings:QuantityMeasurement[Q21a]|:MeasurementName = {"112058", "DCM", "Calcium score"}|:MeasurementValue = "8"-- set value for second measurementsetcontext ImagingReport:Findings:QuantityMeasurement[Q21b]|:MeasurementName = {"408716009", "SNOMED", "Stenotic lesion length"}|:MeasurementValue = "14"|:MeasurementUnits = "mm"Extension and NamespaceIn accordance with CDA R2 (and HL7 v3 XML) extensibility rules, as described in the CDA R2 section 1.4, locally-defined XML markup is specified in this standard where there is a need to communicate information for which there is no suitable representation in CDA R2. These extensions are described in the context of the templates where they are used. All such extensions use HL7 v3 Data Types used by CDA R2. The namespace for these extensions is "urn:dicom-org:PS3-20", which is aliased in this standard as "ps3-20".Extensions created for this standard are:ps3-20:accessionNumber - The accessionNumber extension allows for the clear identification of the imaging department identifier for a service request (order). While this identifier could be conveyed as another id for the inFulfillmentOf/Order element, there is no reliable way in that context to distinguish it from the Placer Order Number. As this is a primary management identifier in departmental workflows, a distinct local markup is defined.ConformanceAs a Creator ApplicationAn application may claim conformance to this Part as a document creator if it creates a CDA document in accordance with one or more of the document level templates defined herein. Templates are logical specifications, and may invoke subsidiary templates. The creator is responsible for the requirements for correct serialization of elements in accordance with the CDA Standard.Note: This is particularly relevant when including “general” templates, whose elements need to be sorted into appropriate sequence locations. E.g., template IDs need to be encoded with the other template IDs of the invoking element.As a Receiver ApplicationAn application may claim conformance to this Part as a document receiver if it performs specialized processing of a CDA document utilizing one or more of the templates defined herein. Note: In general, receivers of CDA documents are expected to follow the fundamental rules of the CDA Standard to support their intended use, and are not expected to assert specific conformance claims for specific CDA templates. However, applications that perform operations using CDA Level 2 (section headings) or Level 3 (structured entries) coded content may assert conformance to specific templates.For example, and application that extracts structured entries about planned follow-up procedures from the Recommendations section and tracks their performance may claim specific conformance to the Recommendations section template.IHE Patient Care Coordination Technical Framework specifies four options for a receiver:View – The receiver can display the document following the rules of the CDA Specification, and using the stylesheet specifications provided by the document source (if any). The receiver allows traversal of links to other documents in the sharing environment.Document Import – The receiver can store the document as a whole and provide local access to it.Section Import – The receiver can display the document, and allow the user to select sections to be copied into local data structures with identification of provenance.Discrete Data Import – The receiver can copy structured entry data into local data structures with identification of provenance.Rendering Header Information for Human Presentation(This section is reproduced from the Consolidated CDA Implementation Guide Section 2.8)Metadata carried in the header may already be available for rendering from electronic medical records (EMRs) or other sources external to the document; therefore, there is no strict requirement to render directly from the document. An example of this would be a doctor using an EMR that already contains the patient’s name, date of birth, current address, and phone number. When a CDA document is rendered within that EMR, those pieces of information may not need to be displayed since they are already known and displayed within the EMR’s user interface. Good practice would recommend that the following be present whenever the document is viewed:Document title and document datesService and encounter types, and date ranges as appropriateNames of all persons along with their roles, participations, participation date ranges, identifiers, address, and telecommunications informationNames of selected organizations along with their roles, participations, participation date ranges, identifiers, address, and telecommunications informationDate of birth for recordTarget(s)As a Document InstanceA CDA document may assert its conformance to a template by inclusion of the specified templateID element in the document, section, or entry. As a Content SpecificationA template document may claim conformance to this Part as a Content Specification if it includes content templates that use one or more of the templates defined herein. Content templates provide further constraints based on subspecialty, procedure type, national regulations, local guidelines, etc. The constraints may include specific requirements for header elements, e.g., to support health information exchange, recommended narrative text, entries for specific observations, binding to vocabulary value sets, etc.Notes:Content templates may reference element Business Names and vocabulary Concept Domain Names, or they may create derived templates with further constraints.Content template conformance should be documented in its metadata by reference to this Standard (PS3.20), the name of the referenced template, and its ID (UID).Document-Level TemplatesDocument-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and sections by refering to templates, and constraints on the vocabulary used in those templates. Imaging Report Template ID 1.2.840.10008.20.x1.x1NameImaging ReportEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description This CDA Imaging Report template defines the report content and technical constraints for documents, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or theuraputic radiology, cardiology, or other imaging reports. The body of an Imaging Report contains five main imaging report sections: Clinical information; Current imaging procedure description;Comparison studies;FindingsImpressionplus potentially an Addendum(s)The report templates sponsored by the RSNA Informatics Reporting initiative () adhere to this general section outline.ClassificationCDA Document LevelRelationships ContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateImagingReportClinicalDocument?>templateId1..1SHALLII??>@@root1..1SHALLUIDSHALL1.2.840.10008.20.x1.x1DocType>code1..1SHALL CDSHALL CWE noNullValue Set CID x7021>1..1SHALL?General Header>1..1SHALL?Imaging Header>0..1MAYParent Document?>component1..1SHALL???>>structuredBody1..1SHALL??>>>component0..1MAY?ClinicalInformation>>>>sectionClinical Information>>>component1..1SHALL?ProcedureDescription>>>>sectionImaging Procedure Description>>>component0..1MAY?ComparisonStudy?>>>>sectionComparison Study>>>component0..1MAY?Findings>>>>sectionFindings>>>component1..1SHALL?Impression?>>>>sectionImpression>>>component0..*COND?Addendum[*]?>>>>sectionAddendumclinicalDocument/codeSome of the codes in Value Set CID x7021are pre-coordinated with either the imaging modality, body part examined, or specific imaging method. When pre-coordinated codes are used, any coded values elsewhere in the document describing the modality, body part, etc., must be consistent with the document type code. Local codes used for report types may be included as a translation element in the code.Figure SEQ Figure \* ARABIC 10: ClinicalDocument/code example<code code=”18748-4” codeSystem=”2.16.840.1.113883.6.1” codeSystemName=”LOINC” displayName=”Diagnostic Imaging Report”/>Figure SEQ Figure \* ARABIC 11: Use of the translation element to include local codes for document type<code code=”18748-4” codeSystem=”2.16.840.1.113883.6.1” codeSystemName=”LOINC” displayName=”Diagnostic Imaging Report”> <translation code=’XRPEDS’ displayName=’Pediatric Radiography Report’ codeSystem=’2.16.840.1.123456.78.9’/></code>Addendum If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator element (i.e., was signed), the component/structuredBody SHALL contain at least one Addendum Section.Interventional Radiology Report (reserved)Similar to diagnostic; includes specific sections or entries for consents, sedation, blood loss, reference to operative report Use Procedure Description rather than Current Imaging Procedure Description?Anatomic Pathology Report (reserved)Kussaibi, et al. “HL7 CDA Implementation Guide for Structured Anatomic Pathology Reports Methodology and Tools” doi:10.3233/978-1-60750-588-4-289 Header Content ModulesThis section describes constraints that apply to the header components. Header constraints specific to each document type are described in the appropriate document level template.General Header ElementsTemplate ID 1.2.840.10008.20.x4.x1NameGeneral Header ElementsEffective DateVersion LabelDICOM-yyyymmddStatusdraftDescription CDA Header Elements for all documents, including primary participationsClassificationCDA Header ElementsRelationships Invoked from all document level templatesContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary Template?typeId1..1SHALLII??@@root1..1SHALLUID2.16.840.1.113883.1.3@@extension1..1SHALLSTPOCD_HD000040documentIDid1..1SHALLIItitletitle1..1SHALLSTcreationTimeeffectiveTime1..1SHALLTSconfidentialityconfidentialityCode1..1SHALLCESHALL CNE STATIC 2010-04-21Value Set x_BasicConfidentialityKind 2.16.840.1.113883.11.16926 languageCodelanguageCode1..1SHALLCSSHALL CNEValue Set CID 5000 LanguagessetIdsetId0..1MAYIIversionNumberversionNumber1..1CONDINTPatient[*]recordTarget1..*SHALL>patientRole1..1SHALL>@@ID1..1CONDXML IDPatientID>>id1..*SHALLIIPatientAddr>>addr1..*SHALLADPatientTele>>telecom1..*SHALLTEL>>patient1..1SHALLPatientName>>>name1..1SHALLPNPatientGender>>>Administra-tiveGenderCode1..1SHALLCESHALL CNEValue Set AdministrativeGender 2.16.840.1.113883.11.1PatientBirthTime>>>birthTime1..1SHALLTS>>providerOrganization0..1MAYproviderOrgName>>>name1..*SHALLONproviderOrgTel>>>telecom1..*SHOULDTELproviderOrgAddr>>>addr1..*SHOULDADlegalAuthenticator0..1CONDSigningTime>time1..1SHALLTS>signatureCode1..1SHALLCSSHALL S>assignedEntity1..1SHALLSignerID>>id1.*SHALLIISignerAddr>>addr1.*SHALLADSignerTel>>telecom1..*SHALLTEL>>assignedPerson1..1SHALLSignerName>>>name1..1SHALLPNAuthor[*]author1..*SHALLAuthoringTime>time1..1SHALLTS>assignedAuthor1..1SHALL>@@ID1..1CONDXML IDAuthorID>>id1.*SHALLIIAuthorAddr>>addr1.*SHALLADAuthorTel>>telecom1..*SHALLTEL>>person1..1SHALLAuthorName>>>name1..1SHALLPNRecipient[*]informationRecipient0..*MAY>intendedRecipient1..1SHALL>@@classCode1..1SHALLCSSHALLASSIGNED>@@ID1..1CONDXML IDRecpientAddr>>addr0.*MAYADRecpientTel>>telecom0..*MAYTEL>>informationRecipient0..1MAYRecpientName>>>name1..1SHALLPN>>receivedOrganization0..1MAYRecpientOrg>>>name1..1SHALLONcustodian1..1SHALL>assignedCustodian1..1SHALL>>representedCustodianOrganization1..1SHALLCustodianOrgID>>>id1.*SHALLIICustodianOrgName>>>name1..*SHALLONCustodianOrgAddr>>>addr1.*SHALLADCustodianOrgTel>>>telecom1..*SHALLTELeffectiveTimeSignifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA setID and versionNumberThe setID and versionNumber elements may be used by the document creation system to manage document revisions, in accordance with the CDA specification sections 4.2.1.7 and 4.2.1.8. COND: If and only if the setID element is present, the versionNumber element SHALL be present.recordTarget/patientRole and @IDThe recordTarget records the patient whose health information is described by the clinical document; it must contain at least one patientRole element. Multiple recordTarget elements should be used only in the case of conjoined twins/triplets who are the subject of a single imaging procedure, or for special cases (e.g., pre-natal surgery, where a medical record has been established for the fetus). COND: If there are multiple recordTarget elements, each patientRole element SHALL include an XML ID attribute that serves as the business name discriminator associated with the instance of the element. Figure SEQ Figure \* ARABIC 12: Header example<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/><!— Imaging Report Release 2 Template --><templateId root="1.2.840.10008.20.1.1"/><!-- General Header Template --><templateId root="2.16.840.1.113883.10.20.22.1.1"/> <id extension="999021" root="2.16.840.1.113883.19"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="18748-4" displayName="Diagnostic Imaging Report"/> <title>Radiology Report</title> <effectiveTime value="20150329171504+0500"/><confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/><languageCode code="en-US" codeSystem="2.16.840.1.113883.6.121"/><setId extension="111199021" root="2.16.840.1.113883.19"/><versionNumber value="1"/>recordTarget/patientRole/Patient/birthTime Patient birthTime SHALL be precise to year, SHOULD be precise to day.Figure SEQ Figure \* ARABIC 13: recordTarget example<recordTarget> <patientRole> <id extension=”12345” root=”2.16.840.1.113883.19”/> <!—Fake ID using HL7 example OID. -> <id extension=”111-00-1234” root=”2.16.840.1.113883.4.1”/> <!—Fake Social Security Number using the actual SSN OID. -> <addr use=”HP”> <!—HP is “primary home” from codeSystem 2.16.840.1.113883.5.1119 -> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> <!—US is “United States” from ISO 3166-1 Country Codes: 1.0.3166.1 -> </addr> <telecom value=”tel:(781)555-1212” use=”HP”/> <!—HP is “primary home” from AddressUse 2.16.840.1.113883.5.1119 -> <patient> <name use=”L”> <!—L is “Legal” from EntityNameUse 2.16.840.1.113883.5.45 -> <prefix>Mr.</prefix> <given>Adam</given> <given qualifier=”CL”>Frankie</given> <!—CL is “Call me” from EntityNamePartQualifier 2.16.840.1.113883.5.43 -> <family>Everyman</family> </name> <administrativeGenderCode code=”M” codeSystem="2.16.840.1.113883.5.1” displayName=”Male”/> <birthTime value=”19541125”/> </patient> <providerOrganization> <id root=”2.16.840.1.113883.19”/> <name>Good Health Clinic</name> <telecom use=”WP” value=”tel:(781)555-1212”/> <addr> <streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> </providerOrganization> </patientRole></recordTarget>LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the correctness of the content of the document and SHALL be present if the document has been legally authenticated. In the context of an imaging report, this means the radiologist, cardiologist, or other profesional who signed or validated the report.Based on local practice, clinical documents may be released before legal authentication. This implies that a clinical document that does not contain this element has not been legally authenticated.The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All clinical documents have the potential for legal authentication, given the appropriate credentials.Note that the legal authenticator, if present, must be a person.The legalAuthenticator SHALL contain exactly one [1..1] time representing the time of signature.Figure SEQ Figure \* ARABIC 14: legalAuthenticator example<legalAuthenticator> <time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></legalAuthenticator>InformationRecipient/intendedRecipient and @IDThe informationRecipient participation elements record the intended recipients of the information at the time the document is created. An intended recipient may be a person (an informationRecipient entity), with or without an organization affiliation (receivedOrganization scoping entity), or simply an organization. If an organization, the document is expected to be incorporated into an information system of that organization (e.g., the electronic medical record for the patient). COND: If there are multiple informationRecipient elements, each intendedRecipient element SHALL include an XML ID attribute that serves as the business name discriminator associated with the instance of the element.Figure SEQ Figure \* ARABIC 15: informationRecipient example<informationRecipient> <intendedRecipient> <informationRecipient> <name> <given>Henry</given> <family>Seven</family> </name> </informationRecipient> <receivedOrganization> <name>Good Health Clinic</name> </receivedOrganization> </intendedRecipient></informationRecipient>author/assignedAuthor and @ID (Person)The author element represents the creator of the clinical document. This template restricts the author to be a person. Such author SHALL contain exactly one [1..1] time representing the start time of the author’s participation in the creation of the content of the clinical document.COND: If there are multiple author elements, each assignedAuthor element SHALL include an XML ID attribute that serves as the business name discriminator associated with the instance of the element. Figure SEQ Figure \* ARABIC 16: Person author example<author> <time value="20050329224411+0500"/> <assignedAuthor> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor></author>Imaging Header ElementsTemplate ID 1.2.840.10008.20.x4.x2NameImaging Header ElementsEffective DateVersion LabelDICOM-yyyymmddStatusdraftDescription CDA Header Elements for imaging reports, including encounter, order, and study contextClassificationCDA Header ElementsRelationships Invoked from Imaging ReportContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary Template?componentOf1..1SHALL>encompassingEncounter1..1SHALLencounterID>>id0..1SHOULDencounterTime>>effectiveTime1..1SHALL>>location0..1MAY>>>healthCareFacility1..1SHALL>>>>location0..1SHOULDHealthcareFacilityName>>>>>name1..1SHALLENHealthcareFacilityAddress>>>>>addr1..1SHALLAD>>>>serviceProviderOrganization0..1SHOULDHealthcareProviderOrganizationName>>>>>name1..1SHALLON>>encounterParticipant0..*MAY>>@@typeCode1..1SHALLATND>>>assignedEntity1..1SHALL>>>>assignedPerson1..1SHALLAttendingPhysicianName>>>>>name1..1SHALLENinFulfillmentOf1..*SHALLOrder[*]>order1..1SHALL>@@ID1..1CONDXML ID>>id1..1SHALLIIOrderAssigningAuthority>>@@root1..1SHALLUIDOrder Placer Identifier Sequence (0040,0026) > Universal Entity ID (0040,0032)OrderPlacerNumber>>@@extension1..1SHALLSTPlacer Order Number/Imaging Service Request (0040,2016)>>ps320:accessionNumber1..1SHALLIIAccessionAssigningAutority>>@@root1..1SHALLUIDIssuer of Accession Number Sequence (0008,0051) > Universal Entity ID (0040,0032)AccessionNumber>>@@extension1..1SHALLSTAccession Number (0008,0050)OrderedProcedureCode>>code0..1SHOULDCERequested Procedure Code Sequence (0032,1064)OrderPriority>>priorityCode0..1SHOULDCEValue Set ActPriority 2.16.840.1.113883.11.16866documentationOf1..*SHALLStudy[*]>serviceEvent1..1SHALL>@@ID1..1CONDXML IDStudyUID>>id1..1SHALLIIStudy Instance UID (0020,000D)ProcedureCode>>code1..1SHALLCEProcedure Code Sequence (0008,1032)Modality>>>translation1..*SHALLCDSHALL CNEModality (0008,0050)AnatomicRegionCode>>>translation0..1SHOULDCDConcept Domain AnatomicRegionProcedureTime>>effectiveTime1..1SHALLTSStudy Date (0008,0020) and Study Time (0008,0030)Performer[*]>>performer0..*MAYPerformerType>>@@typeCode1..1SHALLCSSHALLValue Set x_serviceEventPerformer>>>assignedEntity1..1SHALL>>>@@ID1..1CONDXML IDPerformerID>>>>id1..1SHALLII>>>>assignedPerson1..1SHALLPerformerName>>>>>name1..1SHALLPNparticipant1..1SHALL@@typeCode1..1SHALLCSSHALLREF>assignedEntity1..1SHALLReferrerAddr>>addr0.*SHOULDADReferrerTel>>telecom0..*SHOULDTEL>>assignedPerson1..1SHALLReferrerName>>>name1..1SHALLPNdataEnterer0..1MAY>assignedEntity1..1SHALLTranscriptionistID>>id0..1SHOULDII>>assignedPerson0..1SHOULDTranscriptionistName>>>name1..1SHALLPNcomponentOf/encompassingEncounterThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, Visit Number, or Admission ID, equivalent to DICOM attribute (0038,0010), that number should be present as the ID of the encompassingEncounter.The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.Figure SEQ Figure \* ARABIC 18: componentOf example<componentOf> <encompassingEncounter> <id extension=”9937012” root=”1.3.6.4.1.4.1.2835.12”/> <effectiveTime value=”20060828170821”/> <encounterParticipant typeCode=”ATND”> <templateId root=”2.16.840.1.113883.10.20.6.2.2”/> <assignedEntity> <id extension=”4” root=”2.16.840.1.113883.19”/> <code code=”208D00000X” codeSystem=”2.16.840.1.113883.6.101” codeSystemName=”NUCC” displayName=”General Practice”/> <addr nullFlavor=”NI”/> <telecom nullFlavor=”NI”/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Fay </given> <family>Family</family> </name> </assignedPerson> </assignedEntity> </encounterParticipant> </encompassingEncounter></componentOf>Physician of Record ParticipantThis encounterParticipant with typeCode="ATND" Attender is the attending physician and is usually different from the Physician Reading Study Performer defined in documentationOf/serviceEvent.Figure SEQ Figure \* ARABIC 19: Physician of record participant example<encounterParticipant typeCode=”ATND”> <templateId root=”2.16.840.1.113883.10.20.6.2.2”/> <assignedEntity> <id extension=”44444444” root=”2.16.840.1.113883.4.6”/> <code code=”208D00000X” codeSystem=”2.16.840.1.113883.6.101” codeSystemName=”NUCC” displayName=”General Practice”/> <addr nullFlavor=”NI”/> <telecom nullFlavor=”NI”/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Fay</given> <family>Family</family> </name> </assignedPerson> </assignedEntity></encounterParticipant>inFulfillmentOf/Order and @IDAn inFulfillmentOf element represents the Placer Order. There may be more than one inFulfillmentOf element in the case where a single report is fulfilling multiple orders. There SHALL be one inFulfillmentOf/order for each distinct Order associated with the report. COND: If there are multiple order elements, each order element SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instance of the element.In each inFulfillmentOf/order there SHALL be one order/id for the Placer Order Number (0040,2016).There SHALL be one order/ps3-20:accessionNumber for the DICOM Accession Number (0008,0050) associated with the order. The ps3-20:accessionNumber SHALL be Data Type II; it SHALL have a UID root attribute identifying its assigning authority, and the DICOM Accession Number SHALL be in the extension attribute. Figure SEQ Figure \* ARABIC 20: inFulfillmentOf example<xs:schema ...xmlns:ps3-20="urn:dicom-org:ps3-20"...</xs:schema><inFulfillmentOf> <order> <id extension=”089-927851” root=”2.16.840.1.113883.19.4.33”/> <!-- {root}.33= placer number assigner (CPOE) *-> <ps3-20:accessionNumber root=”2.16.840.1.113883.19.4.27” extension=”10523475” /> <!-- {root}.27= accession number assigner (RIS) *-> </order></inFulfillmentOf>documentationOf/serviceEvent Each documentationOf/serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the report. The main activity being described by this document is both the performance of the imaging procedure and the interpretation of the imaging procedure. There may be more than one documentationOf/serviceEvent elements if the report is interpreting multiple DICOM Studies. There may also be multiple reports for a single DICOM Study.COND: If there are multiple serviceEvent elements, each serviceEvent element SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instance of the element.The serviceEvent/id element contains the DICOM Study Instance UID.The date and time of the imaging procedure is indicated in the serviceEvent/effectiveTime element; the date and time of the interpretation is in the clinicalDocument/effectiveTime. code and translationWithin each documentationOf element, there is one serviceEvent element. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the primary vocabulary to use for describing this event, identified as Procedure Code. The serviceEvent/code/translation elements include codes representing the modality using DICOM (DCM) terminology, and target anatomic region (for which SNOMED terminology is recommended). Notes:1. These codes may be used as health information exchange search metadata in accordance with the IHE Radiology Technical Framework Cross-Enterprise Document Sharing for Imaging (XDS-I) Profile.2. Binding of the Concept Domains ProcedureCode and AnatomicRegion to specific Value Sets may be done in a further profiling of the use of this Template.Figure SEQ Figure \* ARABIC 22: documentationOf example<documentationOf> <serviceEvent classCode="ACT"> <id root="1.2.840.113619.2.62.994044785528.114289542805"/> <!-- study instance UID --> <id extension="123453" root="1.2.840.113619.2.62.994044785528.26"/> <!-- DICOM Requested Procedure ID --> <code code="71020" displayName="Radiologic examination, chest, two views, frontal and lateral” codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/><translation... <effectiveTime value="20060823222400"/> <performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.6.2.1"/> <assignedEntity> <id extension="121008" root="2.16.840.1.113883.19.5"/> <code code="2085R0202X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Diagnostic Radiology"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <given>Christine</given> <family>Cure</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity> </performer> </serviceEvent></documentationOf>PerformerThe documentationOf/serviceEvent may include as a participant the physician reading the study, equivalent to DICOM attribute (0008,1060), and other healthcare professional participants in the procedure (e.g., the surgical performer in an interventional procedure). Note:In simple procedures, the physician reading the study is identified in the Author or LegalAuthenticator participation on the ClinicalDocument, and does not need to be reidentified in this element. The technologist performing the imaging may be identified in this element as a secondary performer, since the interpreting physician is the principal performer responsible for the service event.Figure SEQ Figure \* ARABIC 23: Physician reading study performer example<performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.6.2.1"/> <assignedEntity> <id extension="111111111" root="2.16.840.1.113883.4.6"/> <code code="2085R0202X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Diagnostic Radiology"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <given>Christine</given> <family>Cure</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity></performer>Figure SEQ Figure \* ARABIC 24: participant example<participant typeCode="REF"> <associatedEntity classCode="PROV"> <id nullFlavor="NI"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <associatedPerson> <name> <given>Amanda</given> <family>Assigned</family> <suffix>MD</suffix> </name> </associatedPerson> </associatedEntity></participant>Figure SEQ Figure \* ARABIC 25: dataEnterer example<dataEnterer> <assignedEntity> <id root="2.16.840.1.113883.19.5" extension="43252"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></dataEnterer>Parent Document Header ElementsTemplate ID 1.2.840.10008.20.x4.x3NameParent Document Header ElementsEffective DateVersion LabelDICOM-yyyymmddStatusdraftDescription CDA Header Elements describing relationship to prior/parent documentsClassificationCDA Header ElementsRelationships Invoked from all document level templatesContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary Template?relatedDocument0..1MAY@@typecode1.1SHALLCSSHALLRPLC>parentDocument1..1SHALLReplacedDocumentID>>id1..1SHALLIIReplacedDocumentSetID>>setId0..1MAYIIReplacedDocumentVersion>>versionNumber1..1CONDINT?relatedDocument0..1MAY@@typecode1.1SHALLCSSHALLXFRM>parentDocument1..1SHALLTransformedDocumentID>>id1..1SHALLIIrelatedDocumentA document may have two types of parent document:A superseded version that the present document wholly replaces (typeCode = RPLC). Documents may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report.A source document from which the present document is transformed (typeCode = XFRM). A document may be created by transformation from a DICOM Structured Report (SR) document (see Annex B). The CDA document management vocabulary includes a typeCode APND (append) relationship to a parent document. This relationship type is not supported in this specification; rather, append is effected by creating a replacement document with an Addendum section.parentDocument/setId and versionNumberCOND: If and only if the setID element is present, the versionNumber element SHALL be present.Figure SEQ Figure \* ARABIC 26: relatedDocument example<!-- transformation of a DICOM SR --><relatedDocument typeCode="XFRM"> <parentDocument> <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9"/> <!-- SOP Instance UID (0008,0018) of SR sample document--> </parentDocument></relatedDocument>Section-Level TemplatesThis chapter contains the section-level templates for imaging reports. These templates describe the purpose of each section and the section-level constraints. General requirements for sectionsSection textTemplate ID 1.2.840.10008.20.x4.x0NameSection TextEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description This template specifies the common set of narrative block markup that may be invoked in a CDA imaging report section. ClassificationCDA Element SetRelationships Invoked by all sectionsContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary Templatetexttext1..1CONDEDContent[*]>content0..*MAYST>@@ID1..1SHALLXML IDSee xml ID attributestyle>@@styleCode0..1MAYXML NMTOKENSIntRef[*]>linkHtml0..*MAY>@@href1..1SHALLST (URL - XML IDREF)Graphic[*]>renderMultiMedia0..*MAY>@@referencedObject1..1SHALLXML IDREFExtRef[*]>linkHtml0..*MAY>@@href1..1SHALLST (URL)The text element within the section stores the narrative to be rendered, as described in the CDA R2 specification, and is referred to as the CDA narrative block.COND: The text element SHALL be present if the section content is not completely represented by subsections.As noted in the CDA R2 specification, the document originator is responsible for ensuring that the narrative block contains the complete, human readable, attested content of the section. Structured entries support computer processing and computation and are not a replacement for the attestable, human-readable content of the CDA narrative block. Additional specification information for the CDA narrative block can be found in the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.The narrative block allows a variety of markup. The markup that implements various types of internal and external linkage is shown in the table, and is included in the conformance specifications for each section narrative block that invokes this template. The markup elements may occur at any point within the narrative block text as allowed by the CDA R2 specification. <content> markup and links from entriesThe CDA narrative block may contain the <content> markup element to wrap a block of text so that it can be explicitly identified using its XML ID attribute, and referenced from elsewhere in the document. Specifically, structured entries may link to their equivalent narrative rendering in a content block using the XML ID (see CDA R2 Specification, section 4.3.5.1).Additionally, a content block may include a styleCode attribute to suggest rendering (see CDA R2 Specification, section 4.3.5.11). For example, Bold could also be used to highlight actionable findings in the text of the Findings and/or Impression sections.<linkHtml> markup and internal referencesThe CDA narrative block may contain the <linkHtml> markup to provide a link between narrative text in one section and a content block in another section (see CDA R2 specification section 4.3.5.2). The XML ID of the target content block is used in the linkHtml href attribute, with a prefixed ‘#’ to indicate the reference is in the current document.For example, a linkHtml reference could be used to link an actionable finding in the Impression section to the specific, detailed measurement evidencing a problem that was identified in the text. <renderMultiMedia> markup and graphical contentThe CDA narrative block may contain the <renderMultiMedia> markup element to include graphical content, e.g., a coronary tree diagram or myocardial wall motion “bulls-eye chart”. The renderMultiMedia element links to an observationMedia structured entry using the XML ID of that entry (see CDA R2 Specification, section 4.3.5.6).<linkHtml> markup and external referencesThe CDA narrative block may contain the <linkHtml> markup to provide a link between narrative text and an external (non-attested) resource (see CDA R2 specification section 4.3.5.2).Note:For radiology reports, this capability may be used to tag concepts in the narrative block to concepts defined in the RadLex terminology (), developed by the Radiological Society of North America. The RadLex coded vocabulary is a useful tool for indexing report content for data mining purposes. It is not intended to be a complete grammar for expression of clinical statements, but rather a lexicon for tagging concepts of interest.Within the report section narrative blocks, RadLex codes may be included using the <linkHtml> element and a URI pointing to the RadLex resource. <linkHtml> elements may be embedded in the text at the location of the concept (within the scope of a content tag), or may be provided in a list at the end of the narrative block.Figure SEQ Figure \* ARABIC 26: Example – RadLex references at point of use<section> ... <text> ... <content>There is focal opacity<linkHtml href= /> at the right lung<linkHtml href= /> base most likely representing right lower lobe atelectasis<linkHtml href= />. </content> <content>The mediastinum ...</content></text> ... </section>Figure SEQ Figure \* ARABIC 26: Example– RadLex references at end of narrative block<section><title>Findings</title><text> <content>Pleura normal... </content> <linkHtml href= /></text></section><linkHtml> markup and image referencesThe text elements (and their children) MAY contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is either the visible text of the hyperlink, or a descriptor or identifier of the image, or a (limited resolution) copy of the image.Figure SEQ Figure \* ARABIC 27: WADO reference using linkHtml example<text> ... <paragraph> <caption>Source of Measurement</caption> <linkHtml href="">Chest_PA</linkHtml> </paragraph> ...</text>General Section EntriesTemplate ID 1.2.840.10008.20.x4.x4NameGeneral Section EntriesEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description This template specifies the common set of structured entries that may be invoked in a CDA imaging report section, and an author participation for the section. ClassificationCDA Element SetRelationships Invoked by Findings section and its sub-sections, Clinical Information, and other sectionsContextSiblingOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary Templateauthor0..*MAY>assignedAuthor1..1SHALLAuthorID>>id1.*SHALLII>>person1..1SHALLAuthorName>>>name1..1SHALLPNentry0..*MAYCodedObservation[*]>observation1..1SHALLCoded Observationentry0..*MAYQuantityMeasurement[*] >observation1..1SHALLQuantity Measurement entry0..*MAYObservationMedia[*]>observationMedia1..1SHALLObservation Mediaentry0..*MAYSOPInstance[*]>observation1..1SHALLSOP Instance Observationentry0..*MAY>regionOfInterest0..0SHALL NOTNote that there is no business name associated with this template. Rather, this template is an editorial convenience for template specification, and the business names for the elements of this template are logically part of the business name scope of the invoking template.Figure SEQ Figure \* ARABIC 34: Author example<author><assignedAuthor> <id extension="121008" root="2.16.840.1.113883.19.5"/> <assignedPerson> <name><given>John</given> <family>Blitz</family> <suffix>MD</suffix></name> </assignedPerson></assignedAuthor></author>section/entry A section may contain CDA entries that represent in coded form findings, image references, annotation, and numeric measurements. regionOfInterestSection templates defined in this Standard SHALL NOT use the CDA Region of Interest Overlay entry (classCode="ROIOVL"). If it is desired to show images with graphical annotations, the annotations SHOULD be encoded in DICOM Softcopy Presentation State objects that reference the image. Report applications that display referenced images and annotation may retrieve a rendered image using a WADO reference in accordance with PS3.18, including the image and Presentation State, or other DICOM retrieval and rendering methods. This approach avoids the risks of errors in registering a CDA region of interest annotation with DICOM images, and places all image rendering within the scope of the DICOM Standard.Clinical InformationTemplate ID 1.2.840.10008.20.x2.x1NameClinical InformationEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc.ClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateClinicalInformationsection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x1>id1..1SHALLII>code1..1SHALLCDSHALL(55752-0, LOINC, “Clinical Information”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>component0..1MAYRequest>>section1..1SHALLRequest>component0..1MAYProcedureIndications>>section1..1SHALLProcedure Indications>component0..1MAYHistory>>section1..1SHALLMedical (General) History>0..1MAYGeneral Section EntriesFigure SEQ Figure \* ARABIC 28: Clinical Information section example<section> <templateId root="1.2.840.10008.20.x2.x1" /> <code code="55752-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CLINICAL INFORMATION" /> <title>Clinical Information</title> <text>The patient was admitted to the hospital ... </text></section>Imaging Procedure Description Template ID 1.2.840.10008.20.x2.x2NameImaging Procedure DescriptionEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description The Imaging Procedure Description section records the technical details of the procedure and may include information about protocol, imaging device, contrast, radiation dose, medications administered (sedation, stress agents), etc.ClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateProcedureDescriptionsection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x2>id0..1MAYII>code1..1SHALLCESHALL(55111-9, LOINC, “Current Imaging Procedure Description”) title>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry1..1SHALLprocedureTechnique>>procedure1..1SHALLProcedure Technique>entry0..*MAYproceduralMedication[*]>>substanceAdministration1..1SHALLProcedural Medication>component0..1MAYComplications>>section1..1SHALLComplications Section>component0..1CONDRadiationExposure>>section1..1SHALLRadiation Exposure and Protection Information>component1..1SHALLDICOMObjectCatalog>>section1..1SHALLDICOM Object Catalog Section>entry1..1MAYImageQuality>>observation1..1SHALLImage Qualitycomponent/section Radiation Exposure and Protection InformationCOND: If the documented service utilizes ionizing radiation, a Radiation Exposure and Protection Information Section MAY be present.Figure SEQ Figure \* ARABIC 29: Current Imaging Procedure description section example<section> <templateId root="1.2.840.10008.20.x2.x2" /> <code code="55111-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CURRENT IMAGING PROCEDURE DESCRIPTION" /> <title>Current Imaging Procedure Description</title> <text>A CT study was acquired with 2.5 mm images of the abdomen and pelvis with 140 mL of... </text> <! ---see examples for other sections/entries /></section>Comparison StudyTemplateID 1.2.840.10008.20.x2.x3NameComparison StudyEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Documentation of a prior Imaging Procedure to which the current images were comparedClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateComparisonStudysectoion1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x3>id1..*SHALLII>code1..1SHALLCD(18834-2, LOINC, “Radiology Comparison study”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry0..*MAYprocedureTechnique>>procedure1..1SHALLImaging Procedure Technique>entry0..*MAYStudy[*]>>act1..1SHALLStudy Act>0..1MAYGeneral Section EntriesFigure SEQ Figure \* ARABIC 30: Comparison study section example<section> <templateId root="1.2.840.10008.20.x2.x3" /> <code code="18834-2” codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Radiology Comparison Study" /> <title>Comparison Study</title> <text>A prior CT with contrast performed on May 7, 2012, showed that... </text></section>Findings Template ID 2.16.840.1.113883.10.20.6.1.2NameFindingsEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Records clinically significant observations confirmed or discovered during the procedure.ClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision History From Consolidated CDA r1.1DICOM-yyyymmdd: Added optional subsections and entriesBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateFindingssection>templateId1..1SHALLII>@@root1..1SHALLUID2.16.840.1.113883.10.20.6.1.2>id1..*SHALLII>code1..1SHALLCDSHALL(59776-5, LOINC, "Procedure Findings")title>title1..1SHALLSTtext>text1..1CONDEDSection Text>component0..*MAYOBUSFetusFindings[*]>>section1..1SHALLOBUS Fetus Findings>component0..*MAYSubsection[*]>>section1..1SHALLLabeled Subsection>0..1MAYGeneral Section EntriestextIf entries are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text.Figure SEQ Figure \* ARABIC 31: Findings section example<section> <templateId root="2.16.840.1.113883.10.20.6.1.2"/> <code code="121070" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Findings"/> <title>Findings</title> <text> <paragraph> <caption>Finding</caption> <content ID="Fndng2">The cardiomediastinum is... </content> </paragraph> <paragraph> <caption>Diameter</caption> <content ID="Diam2">45mm</content> </paragraph> ... </text> <entry> <templateId root="2.16.840.1.113883.10.20.6.2.12"/> ... </entry> </section>ImpressionTemplate ID 1.2.840.10008.20.x2.x4NameImpressionEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description The most important diagnoses or other clinical conclusions that can be made from the imaging observations and other clinical information are recorded here. This section may include recommendations for additional imaging tests or other actions, as well as global assessments, such as BI-RADS Categories or the equivalent.ClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateImpressionsection1..1SHALL>templateId1..1SHALLII1.2.840.10008.20.x2.x4>@@root1..1SHALLUID>id1..*SHALLII>code1..1SHALLCDSHALL(19005-8, LOINC, "Impressions")title>title1..1SHALLSTtext>text1..1CONDEDSection Text>component0..1MAYCommunicationOfActionableFindings>>section1..1SHALLCommunication of Actionable Findings>component0..1MAYKeyImages>>section1..1SHALLKey Images>component0..*MAYRecommendation>>section1..1SHALLRecommendation>entry0..*MAYcodedObservation>>observation1..*MAYCDCoded ObservationFigure SEQ Figure \* ARABIC 32: Impression section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.27" /> <code code="121072" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Impression" /> <title>Impression</title> <text>This exam identified… </text> <!--- other sections and entries here ---/></section>AddendumTemplate ID 1.2.840.10008.20.x2.x5NameAddendumEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Addendum section for imaging report includes supplemental information added to the original document contents.In this section, Addendums are presented as text (not coded entries).ClassificationCDA Section LevelRelationships Invoked by Imaging Report Document Level TemplateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateAddendum[*]section1..1SHALL@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALLUIDSHALL1.2.840.10008.20.x2.x5>id1..*SHALLII>code1..1SHALLCDSHALL(55107-7 LOINC, "Addendum") title>title1..1SHALLSTtext>text1..1CONDEDSection Text>author1..1SHALLtime>>time1..1SHALLTS>>assignedAuthor1..1SHALLauthorID>>>id1..*SHALLII>>>>person1..1SHALLauthorName>>>>>name1..1SHALLPN>component0..1MAYCommunicationOfActionableFindings>>section1..1SHALLCommunication of Actionable Findingssection/@IDThe Addendum section SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template. Even if only one Addendum section is intantiated, the ID attribute shall be present.authorNote that the Author identified in the document header is the author of the original report, as that participation sets the default authoring context for the report. The Author participation in this section shall be present, and identifies the author of the addendum, even if the same as the author of the original ponent/section - Communication of Actionable FindingsIt is possible for an imaging report to be legally signed (authenticated) prior to the Actionable Findings being properly communicated. In this event, an addendum to the imaging report is often created to document the communication of the actionable findings. This can be included in the text of the Addendum or as a coded element using the Communication of Actionable Findings section.Figure SEQ Figure \* ARABIC 33: Addendum section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.27"/> <code code="55107-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName=" Addendum"/> <title> Addendum Document</title> <text> The supplemental information added to the original document contents...</text> <author> <time value=”20140605143000+0500”/> <assignedAuthor> <id extension=”xyz” root=”2.16.840.1.113883.19.5”/> <assignedPerson> <name> <given>Henry</given> <family>Radiologist</family> </name> </assignedPerson> </assignedAuthor></author></section>Sub-sectionsRequestTemplate ID 1.2.840.10008.20.x2.x6NameRequestEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Information on requested imaging studies and associated tests. It may include information on the reason for the request.ClassificationCDA Section LevelRelationships Invoked by Clinical Information Section Level templateContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateRequestsection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x6>id1..*SHALLII>code1..1SHALLCD(55115-0, LOINC, “Request”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>0..1MAYGeneral Section EntriesFigure SEQ Figure \* ARABIC 35: Request section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.27" /> <code code="55115-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="REQUEST" /> <title>Request</title> <text>PTA (Iliac Angioplasty) for treatment of symptomatic artherosclerotic disease in both iliac arteries ... </text></section>Procedure IndicationsTemplate ID 1.2.840.10008.20.x2.x12NameProcedure IndicationsEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Records details about the reason for the procedure. This section may include the pre-procedure diagnosis or diagnoses as well as one or more symptoms that contribute to the reason the procedure is being performed.ClassificationCDA Section LevelRelationships Invoked by Clinical Information Section Level templateContextOpen/ClosedOpenRevision HistoryFrom Consolidated CDA r1.1, 2.16.840.1.113883.10.20.22.2.29DICOM-yyyymmdd: adapted to use optional Coded Observation entry rather than optional Indication entry Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateProcedureIndicationssection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x12>id1..*SHALLII>code1..1SHALLCD(59768-2, LOINC, “Procedure Indications”) title>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry0..*MAYcodedObservation[*]>>observation1..1SHALLSee bindingCoded Observationentry/observation The binding to the Coded Observation concept domains shall be: Concept Domain or ElementBindingObservationType432678004, SNOMED, “Indication for procedure”Other concept domainsunspecifiedNote:In Consolidated CDA r1.1 the binding to the observationType is to Value Set Problem Type (2.16.840.1.113883.3.88.12.3221.7.2) with conformance SHOULD. Values from that Value Set are acceptable here as well.Figure SEQ Figure \* ARABIC 36: Procedure indications section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.29"/> <code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE INDICATIONS"/> <title>Procedure Indications</title> <text>The procedure is performed as a follow-up for abnormal screening result. </text></section>Medical (General) HistoryTemplate ID 2.16.840.1.113883.10.20.22.2.39NameMedical (General) HistoryEffective Date2012-07Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.ClassificationCDA Section LevelRelationships Invoked by Clinical Information Section Level templateContextOpen/ClosedOpenRevision HistoryFrom Consolidated CDA r1.1DICOM-yyyymmdd: Addition of optional entriesBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateHistorysection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID2.16.840.1.113883.10.20.22.2.39>id1..*SHALLII>code1..1SHALLCD(11329-0, LOINC, “History General”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>0..1MAYGeneral Section Entriessection/textIn the context of an Imaging Report, the section/text should document any contraindications to contrast administration or other procedure techniques that affected the selection or performance of the protocol.Figure SEQ Figure \* ARABIC 37: Medical (General) History section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.39" /> <code code="11329-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History General" /> <title>Relevant medical history</title> <text><list> <item>Patient reported adverse reaction to iodine. </item> <item>Patient is smoker (1 pack daily). </item> </list></text></section>Complications Section Template ID 2.16.840.1.113883.10.20.22.2.37NameComplications SectionEffective Date2012-07Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.ClassificationCDA Section LevelRelationships Invoked in Imaging Procedure Description sectionContextOpen/ClosedOpenRevision HistoryFrom Consolidated CDA r1.1DICOM-yyyymmdd: Addition of optional entriesBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateComplicationssection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID2.16.840.1.113883.10.20.22.2.37>id1..*SHALLII>code1..1SHALLCDSHALL(55109-3, LOINC, “Complications”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry0..*MAYCodedObservation[*]>>observationCoded ObservationFigure SEQ Figure \* ARABIC 38: Complications section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.37"/> <code code="55109-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complications"/> <title>Complications</title> <text>A small post-procedure right pneumothorax is present. </text> <entry> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.13"/> <!-- Code Observation --> ... </observation> </entry></section>Radiation Exposure and Protection InformationTemplate ID 1.2.840.10008.20.x2.x7NameRadiation Exposure and Protection InformationEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Contains information related to the radiation exposure and protection of the patient, as may be required by national or local legal requirements or standards.ClassificationCDA Section and Entry LevelRelationships Invoked by Imaging Procedure Description sectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateRadiationExposuresection1..1SHALL>templateId1..1SHALLII>>@@root1..1SHALLUID1.2.840.10008.20.x2.x7>code(73569-6, LOINC, “Radiation exposure and protection information”)>id1..1SHALLIItitle>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry0..1COND>>procedure1..1SHALL>>@@moodCode1..1SHALLCSEVN>>>code1..1SHALLCD(99SUP155-1, DCM, "Patient exposure to ionizing radiation")>>>participant1..1SHALL>>@@typeCode1..1SHALLCSSHALLRESP>>>participantRole1..1SHALLIrradiationAuthorizingID>>>>id1..1SHALLII>>>>functionCode1..1SHALLCESHALL(113850, DCM, "Irradiation Authorizing") >>>>playingEntity1..1SHALLIrradiationAuthorizingName>>>>>name1..1SHALLPN>entry0..1MAYSOPInstance[doseReport]>>observation1..1SHALLSOP Instance Observation>entry0..1CONDcodedObservation[pregnancy]>>observation1..1SHALLSee bindingCoded Observation>entry0..1MAYcodedObservation[indication]>>observation1..1SHALLSee bindingCoded Observation>entry0..*MAYquantityMeasurement[*]>>observation1..1See bindingQuantity Measurement>entry0..1MAY>>substanceAdministration>>@@classCode1..1SHALLSHALLSBADM>>@@moodCode1..1SHALLSHALLEVN>>>code1..1(440252007, SNOMED, "Administration of radiopharmaceutical")RadioactivityDose>>>doseQuantity0..1SHOULDPQ>>>consumable1..1SHALL>>>>manufacturedProduct1..1SHALL>>>>>material1..1SHALLRadiopharmaceutical>>>>>>code1..1SHALLCESHOULDCWEValue Set CID 25 Radiopharmaceuticals, or CID 4021 PET radiopharmaceuticalstextThe section text SHALL contain:information on the indications for the procedurethe name of the “Irradiation Authorizing” person who is the clinician responsible for determining that the irradiating procedure was appropriate for the indications.summary information on radiation exposure if and only if ionizing is applied in the context of the current procedure (detailed specification of exposure is out of the scope of this textual summary).information on the radioactive substance administered if and only if radioactive substance is administered in the context of the current procedure.entry/procedure Patient ExposureCOND: If modality is CT, MG, NM, PT, XR, XA, or XF, the section SHOULD contain a procedure entry for the exposure of the patient to ionizing radiationThis entry SHALL have a participant, the irradiation authorizing person who is the clinician responsible for determining that the irradiating procedure was appropriate for the indications. Note:This may be the same person as the performing physician identified in the header.entry/observation SOP InstanceThe section may include a reference to a DICOM Dose Report SOP Instance that provides a detailed record of exposure.entry/observation PregnancyCOND: A coded observation entry SHALL be present if the patient is female and child-bearing age. The binding to the Coded Observation concept domains SHALL be: Concept Domain or ElementBindingObservationType364320009, SNOMED, "Pregnancy observable"ObservationValueValue Set CID 6096 DICOM Pregnancy StatusOther concept domainsunspecifiedentry/observation Indication An indication for procedure recorded in this section should be consistent with any indications identified in the Clinical Information and/or Procedure Indications section. It is included here for conformance with regulatory requirements in some jurisdictions for the indications to be specified in the context of the radiation exposure information. The binding to the Coded Observation concept domains SHALL be: Concept Domain or ElementBindingObservationType432678004, SNOMED, “Indication for procedure”Other concept domainsunspecifiedentry/observation Dose measurements The section may include multiple dose measurements. The binding to the Quantity Measurement concept domains SHALL be: Concept Domain or ElementBindingObservationTypeValue Set CID x10040 Summary Radiation Exposure QuantitiesOther concept domainsunspecifiedFigure SEQ Figure \* ARABIC 39: Radiation Exposure and Protection section example<section> <templateId root="XXXX" /> <code code="73569-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RADIATION EXPOSURE AND PROTECTION INFORMATION" /> <title> Radiation exposure and protection information </title> <text>This is going to be a lot of work tocreate this example, so let’s get the table finished first so I don’t need to repeat ... </text></section>Key ImagesID 1.3.6.1.4.1.19376.1.4.1.2.14NameKey ImagesEffective Date2011-07Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description The Key Images section contains narrative description of and references to DICOM Image Information Objects that illustrate the findings of the procedure reported.ClassificationCDA Section LevelRelationships Invoked in Impression sectionContextOpen/ClosedOpenRevision HistoryFrom IHE Cardiac Imaging Report Content DICOM-yyyymmdd: Addition of optional inline image (observationMedia)Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateKeyImagessection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.3.6.1.4.1.19376.1.4.1.2.14>id1..*SHALLII>code1..1SHALLCD(55113-5, LOINC, “Key Images”)title>title1..1SHALLSTtext>text1..1CONDEDSection Text>entry0..*SHOULDSOPInstance[*] >>observation1..1SHALLSOP Instance Observation>entry0..*MAYGraphic[*]>>observationMedia1..1SHALLObservation Mediasection/textThe Key Images section text SHALL contain image references using linkHtml elements, where @href is a valid Web Access to DICOM Persistent Object (WADO) URL. See section 9.1.1.5. The text content of linkHtml should be either visible text of the hyperlink, or a descriptor or identifier of the image, or a (limited resolution) copy of the image (see section 9.8.7.3). SOP Instance ObservationThe Key Images section SHOULD include SOP Instance Observation entries equivalent to the linkHtml image references.observationMediaThe Key Images section MAY include observationMedia entries with in-line encoded copies of the referenced images, linked into the narrative block using the renderMultiMedia markup. See section 9.1.1.3. The renderMultiMedia may be positioned within the linkHtml markup. These in-line encoded images may have limited resolution and lossy compression as appropriate for inclusion in a report.Figure SEQ Figure \* ARABIC 40: Key Images section example<section> <templateId root="1.3.6.1.4.1.19376.1.4.1.2.14" /> <code code="55113-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Key Images" /> <title>Key Images</title> <text>Maximum extent of tumor is shown in <linkHtml href=; image 1 <renderMultiMedia referencedObject="refimag1" /> </linkHtml> </text> <entry> <!--SOP Instance reference> <observation classCode=DGIMG moodcode=EVN ID="SOP1-2"> </entry> <entry> <!--inline rendered image> <observationMedia ID="refimag1"> <value representation=B64 mediaType="image/jpeg"> Bgd3fsET4g... </value> </observationMedia> </entry></section>DICOM Object Catalog Template ID 2.16.840.1.113883.10.20.6.1.1NameDICOM Object Catalog SectionEffective Date2012-07Version LabelCCDA-1.1StatusApproved Description DICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects. The DICOM Object Catalog section is not intended for viewing and may contain empty section text.ClassificationCDA Section LevelRelationships Invoked by Imaging Procedure Description SectionContextOpen/ClosedOpenRevision History From Consolidated CDA r1.1Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateDICOMCatalogsection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID2.16.840.1.113883.10.20.6.1.1>id1..*SHALLII>code1..1SHALLCD(121181, DCM, "Dicom Object Catalog") title>title1..1SHALLtext>text1..1CONDEDSection Text>entry0..*SHOULDStudy[*]>>act1..1SHALLStudy Act 2.16.840.1.113883.10.20.6.2.6Figure SEQ Figure \* ARABIC 41: DICOM object catalog section example<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.1.1"/> <code code="121181" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="DICOM Object Catalog"/> <entry> <!-- **** Study Act **** --> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.6"/> <id root="1.2.840.113619.2.62.994044785528.114289542805"/> <code code="113014" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Study"/> <!-- **** Series Act****--> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <id root="1.2.840.113619.2.62.994044785528.20060823223142485051"/> <code code="113015" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Series"> ... </code> <!-- **** SOP Instance UID *** --> <!-- 2 References --> <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/> ... </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/> ... </observation> </entryRelationship> </act> </entryRelationship> </act> </entry></section>OBUS Fetus FindingsTemplate ID 1.2.840.10008.20.x2.x8NameOBUS Fetus FindingsEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Records observations related to a fetus confirmed or discovered during an obstetric ultrasound imaging procedure.ClassificationCDA Section LevelRelationships Invoked in Findings sectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateOBUSFetusFindings[*]section1..1SHALL@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALL1.2.840.10008.20.x2.x8>id1..*SHALLII>code1..1SHALLCD(12129-3, LOINC, "Fetal Study observation general US")title>title1..1SHALLSTtext>text1..1CONDEDSection Text>subject1..1SHALL>>relatedSubject1..1SHALL>>>Code1..1SHALLCE(121026 DCM, "Fetus") >>>subject1..1SHALLFetusID>>>>Name1..1SHALLPN>component0..*MAYSubsection[*]>>section1..1SHALLLabeled Subsection>0.1MAYGeneral section EntriesFor reports on mothers and their fetus(es), information on a mother is mapped to recordTarget, PatientRole, and Patient. Information on the fetus is mapped to subject, relatedSubject, and SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.section/@IDThe OBUSFetusFindings sub-section SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template. Even if only one fetus findings sub-section is intantiated, the ID attribute shall be present.Example:The business name for the narrative text in a subsection about fetus A might be ImagingReport:Findings:OBUSFetusFindings[FetusA]:textFetusIDThe subject/relatedSubject/subject/name element is used to store the DICOM fetus ID, typically a pseudonym such as “fetus A”. This is in addition to the identification in the XML ID attribute, and shall be present even if only one fetus is identified in the document.Figure SEQ Figure \* ARABIC 42: OBUS Fetus Findings section example<section> <templateId root="2.16.840.1.113883.10.20.22.2.27" /> <code code="12129-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Fetal Study observation general US" /> <title>Fetus A</title> <text>Estimated gestational age of 27 weeks... </text> <relatedSubject> <code code="121026" codeSystem="1.2.840.10008.2.16.4" displayName="Fetus"/> <subject> <name>fetus A</name> </subject> </relatedSubject></section>Labeled SubsectionTemplate ID 1.2.840.10008.20.x2.x9NameLabeled SubsectionEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description Narrative or coded subsection that allows organization of content for a labeled topic (a particular organ or anatomic feature, a lesion, a tumor, etc.). The section.code shall be absent, but the section.title shall be present.The attribute ID may be defined in advance by a radiology report template (e.g., “liver”) or dynamically by the report creator device (eg., for multiple tumors).ClassificationCDA Section LevelRelationships Invoked in Findings SectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateSubsection[*]section1..1SHALL@@IDXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALL1.2.840.10008.20.x2.x9>id1..*SHALLII>code0..0SHALL NOTtitle>title1..1SHALLnoNullSTSee titletext>text1..1CONDEDSection Text>component0..*MAYSubsection[*]>>section1..1SHALLLabeled Subsection>0..1MAYGeneral section EntriestitleThe title element is used to identify the topic (specific organ or anatomic feature, abnormality, lesion, etc.) as the subject of the sub-section findings in the human readable document. As there is no section.code, this is the required mechainsm to represent the section purpose as free ponent/section Labeled SubsectionThis template invokes itself recursively to allow arbitrarily deep nested subsections.Figure SEQ Figure \* ARABIC 43: Labeled sub-section example<section ID="Liver"> <templateId root="2.16.840.1.113883.10.20.22.2.27" /> <title>Liver</title> <text>No evidence of cirrhosis, nodular regeneration, or ... </text></section>Communication of Actionable FindingsTemplate ID 1.2.840.10008.20.x2.x10NameCommunication of Actionable FindingsEffective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description A section that documents the notification of an actionable finding to a provider or other person responsible for patient care. The documentation in narrative text, and optionally in a coded entry, includes by whom, to whom, and at what date/time.Specific findings, including actionable (aka critical) findings documented in text or as coded entries, are typically found in the Findings Section. The actionable findings may be duplicated in the Impression Section in either text or as coded entries. The actionable findings may be new (critical) or a change to a previous report/diagnosis (discrepant).ClassificationCDA Section and Entry LevelRelationships Invoked in Impression and Addendum sectionsContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateCommunicationOfActionable Findingssection1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x2.x10>id1..*SHALLII>code1..1SHALLCDSHALL(73568-8, LOINC, "Communication of Critical Results") >text1..1SHALLEDContent[*]>>content0..*SHALLSTSee section/text/content - narrative>>@@ID1..1SHALLXML IDfindingRef[*]>>>linkHtml0..*MAYURL (XML IDREF)#findingRef>entry0..*SHOULDcommunication[*]>>act1..1SHALLSHALL>>@@classCode1..1SHALLCSACT>>@@moodCode1..1SHALLCSEVN>>>code1..1SHALLCDSHOULD(99SUP155-5, 99SUP155, “results communicated”)commTime>>>effectiveTime1..1SHALLTS SHALL>>>text1..1SHALLEDref>>>>reference1..1SHALLURL (XML IDREF)#contentRef>>>performer1..1SHALL>>>>assignedEntity1..1SHALL>>>>>assignedperson1..1SHALLreportingPhysicianName>>>>>>name1..1SHALLPN>>>participant1..1SHALL>>>@@typeCode1..1SHALLCSNOT>>>>participantRole1..1SHALLnotificationContactTelecom>>>>>telecom1..1SHALLTEL>>>>>playingEntity1..1SHALLnotificationContactName>>>>>>name1..1SHALLPNsection/text/content - narrativeEach documented act of communication of actionable findings SHALL be included as narrative in a section/text/content element, labeled with an XML ID (see Section 9.1.1.1). Note:The following text content for such a block is specified in the RSNA Radiology Reporting Templates, Template 297: Communication of Actionable Finding ():method [discussed directly | discussed by telephone | described in message] by [ person ] to [ person ] on [<date>] at [<time>] The documentation may also provide a linkHtml reference to either the actionable finding narrative elsewhere in the report, e.g., in the Findings or Complications section, and/or to the structured entry of that finding (see Section 9.1.1.2).entry/actA structured entry representation of the act of communication MAY be included in the section. This entry does not necessarily represent the entirety of the act as described in the narrative text, e.g., the communication method and actual content of the communication is not represented, nor whether the receiver acknowledged the communication (“read-back”). The act/text/reference element SHALL include an XML IDREF value pointing to the associated narrative content block. entry/act/effectiveTimeThe entry/act/effectiveTime element represents the date and time that actionable findings were communicated. The time that the findings were first observed is recorded in the effectiveTime element of the original observation, as linked through the section/text/content/linkHtml element.entry/act/participantThe entry/act/effectiveTime element represents the notified party (typecode = "NOT"). This could be the patient.Figure SEQ Figure \* ARABIC 44: Communication of Actionable Results section example<section> <templateId root="1.2.840.10008.20.x2.x10" /> <code code="73568-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Communication of Critical Results" /> <title>Communication of Actionable Results</title> <text>Dr. Smith was phoned at 262-966-0120 at 3:14pm on Wednesay, June 4, 2014, and the incidental finding was discussed directly with Dr. Smith to explain... </text> <! – see Actionable Results Urgency entry example --- /></section>RecommendationTemplate ID 1.2.840.10008.20.x2.x11NameRecommendation Effective Date(Date of Final Text adoption)Version LabelDICOM-yyyymmddStatusDraft (will change to Approved on Final Text adoption)Description This section provides a separate heading/title to describe the study interpreter’s recommendations for follow-up studies or procedures.ClassificationCDA Section LevelRelationships Invoked in Impression sectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateRecommendationsection>templateId1..1SHALLIISHALL>@@root1..1SHALLUID1.2.840.10008.20.x2.x11>id1..*SHALLII>codeSHALL(18783-1, LOINC, “Study recommendation”) title>title0..1MAYSTtext>text0..1SHALLEDContent[*]>>content0..*SHALLSTSee section/text/content - narrative>>@@ID1..1SHALLXML IDguidelineRef>>>linkHtml0..1MAYURI>entry0..*MAYfollowupProcedure[*]>>procedure1..1SHALL>>@@ID1..1SHALLXML IDSee xml ID attribute>>@@moodCode1..1SHALLCSSHALLPRPProcedureCode>>>code1..1SHALLCDMAYCWEConcept Domain RecommendedFollow-upWhen>>>effectiveTime1..1SHOULDIVL<TS>>>>text1..1SHALLEDref>>>>reference1..1SHALLURL (XML IDREF)#contentReftext/content Each documented recommendation SHALL be included as narrative in a section/text/content element, labeled with an XML ID (see Section 9.1.1.1). If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element.entry/procedure and @IDThe Recommendation section may include entries for recommended follow-up procedures. Each entry/procedure SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the element. Even if only one procedure entry is intantiated, the ID attribute shall be present.entry/procedure/codeAn example binding for Concept Domain Recommended Follow-up would be Value Set CID 6028 Mammography Recommended Follow-up.entry/procedure/effectiveTimeThe HL7v3 TS Data Type used for effectiveTime requires the specification of a absolute date, rather than a date relative to the date of the report. Thus the concept “follow-up within one year” needs to be encoded as a TS with an effectiveTime/high element value one year after the date of the report.entry/procedure/text/referenceThe procedure entry SHALL include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative content block. See Section 9.1.1.1.Figure SEQ Figure \* ARABIC 45: Radiology recommendation section example<section> <templateId root="1.2.840.10008.20.x2.x11" /> <code code="18783-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RADIOLOGY STUDY RECOMMENDATION" /> <title>Radiology Recommendation</title> <text><content ID="rec01">Biopsy should be considered. Follow-up at short interval. </content> </text></section>Entry-level TemplatesThis part of the guide describes the clinical statement entry templates used within the sections of documents. Entry templates contain constraints that are required for conformance. Note that the clinical statement templates are presented in alphabetical order; templates are not grouped by possible containing templates. Entry-level templates are always allowed in sections.Each entry-level template description contains the following information:Key template metadata (e.g., templateId, etc.)Description and explanatory narrative.Required CDA acts, participants and vocabularies.Optional CDA acts, participants and vocabularies.Several entry-level templates require an effectiveTime:The effectiveTime of an observation is the time interval over which the observation is known to be true. The low and high values should be as precise as possible, but no more precise than known. While CDA has multiple mechanisms to record this time interval (e.g., by low and high values, low and width, high and width, or center point and width), we constrain most to use only the low/high form. The low value is the earliest point for which the condition is known to have existed. The high value, when present, indicates the time at which the observation was no longer known to be true. The full description of effectiveTime and time intervals is contained in the CDA R2 normative edition.Entry-level templates may also describe an id element, which is an identifier for that entry. This id may be referenced within the document, or by the system receiving the document. The id assigned must be globally unique. Coded ObservationTemplate ID 2.16.840.1.113883.10.20.6.2.13NameCoded ObservationEffective DateVersion LabelDICOM-yyyymmddStatusDescription Qualitative or categorical observation using a value of type CD.ClassificationCDA Entry LevelRelationships Invoked from all sectionsContextOpen/ClosedopenRevision HistoryFrom Consolidated CDA r1.1DICOM-yyyymmdd: Added optional negationInd, interpretationCode, targetSiteCode, and methodCode with business names; added optional subject Coded Observation Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateCodedObservation[*]observation@@ID1..1SHALLXML IDSee xml ID attribute@@moodCode1..1SHALLSHALL“EVN”not@@negationInd0..1MAYBLSHALL"true">templateId1..1SHALLII>@@root1..1SHALLSHALL2.16.840.1.113883.10.20.6.2.13>id1..1SHALLIIObsName>code1..1SHALLCDConcept Domain ObservationTypeObsValue>value1..1SHALLCDConcept Domain ObservationValueTime>effectiveTime0..1SHOULDTSInterpretationCode>interpretationCode0..1MAYCESHALL CNEValue Set ObservationInterpretation ActionableFindingCode>>translation0..1MAYCDMAY CWEValue Set CID x7035See interpretationCode and translation>@@xsi:type1..1SHALLSTSHALLCDTargetSite>targetSiteCode0..1MAYCDConcept Domain ObservationSiteMethod>methodCode0..1MAYCDConcept Domain ObservationMethod>text0..1SHOULDEDref>>reference1..1SHALLURL (XML IDREF)#contentRef>entryRelationship0..*MAY>@@typeCode1..1SHALLCSSHALLSPRTSOPInstance[*]>>observation1..1SHALLSOP Instance Observation>entryRelationship0..*MAY>@@typeCode1..1SHALLCSSHALLSPRTQuantityMeasurement[*]>observation1..1SHALLQuantity Measurement >entryRelationship0..*MAY>@@typeCode1..1SHALLCSSHALLSUBJCodedObservation[*]>observation1..1SHALLCoded Observationobservation/@IDThe Coded Observation entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template. code and @negationIndThe Observation code element has an associated Concept Domain ObservationType. A representative binding for this Concept Domain is to the value (ASSERTION, actcode[2.16.840.1.113883.5.4], “Assertion”), providing an assertion of a finding concept in the value element.The Observation may have @negationInd attribute "true", which together with the code "ASSERTION" indicates that the finding was not observed, e.g., to represent “No finding of stroke”. Note:This is the pattern used in Consolidated CDA for negative findings.text/reference and Related Narrative Block MarkupThe Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element of the Observation class) SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.interpretationCode and translationWhen an observation is unexpected or “actionable”, it may be flagged using the interpretationCode. For very abnormal findings the interpretationCode element SHALL be set to abnormal alert (“AA”). Unexpected normal findings, e.g., no findings of disease when patient treatment had been planned on the presumption of disease, may also be flagged using interpretationCode normal (“N”).The translation element of the interpretationCode may be used to provide a further classification as defined in a regionally- or professionally-specified value set. This template identifies an optional value set for the ACR Actionable Finding categories 1, 2, and 3, as defined by: Larson PA, et al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016.entryRelationship/@typeCode=SUBJ/observation - codedThe Coded Observation entry MAY include an actRelationship of type SUBJ (has subject) to a subsidiary Coded Observation. This allows the constructions of complex clinical statements.Figure SEQ Figure \* ARABIC 46: Coded observation example<observation classCode="OBS" moodCode="EVN" ID="obs-1" > <templateId root="2.16.840.1.113883.10.20.6.2.13"/> <code code="18782-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Study observation"/> <statusCode code="completed"/> <value xsi:type="CD" code="309530007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hilar mass"/> <!-- entryRelationship elements referring to SOP Instance Observations or Quantity Measurement Observations may appear here --></observation>Procedural Medication Template ID 1.2.840.10008.20.x3.x1NameProcedural MedicationEffective DateVersion LabelDICOM-yyyymmddStatusDescription Procedural medication describes a substance administration that has actually occurred prior to or during a procedure (e.g., imaging contrast/agents, anti-histamines, anti-anxiety, beta blockers to control heart rate during procedure, etc.).ClassificationCDA Entry LevelRelationships Invoked in Imaging Procedure Description sectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateproceduralMedication[*] or Contrast[*]substanceAdministration1..1SHALL@@ID1..1SHALLXML IDSee xml ID attribute@@classCode1..1SHALLCSSHALLSBADM@@moodCode1..1SHALLCSSHALLEVN>templateId1..1SHALLII>@@root1..1SHALLUIDSHALL1.2.840.10008.20.x3.x1>id1..1SHALLII>text0..1SHOULDED>>reference0..1SHOULDURL (XML IDREF)#contentRef>statusCode1..1SHALLCSSHALLCOMPLETEDroute>routeCode0..1MAYCEValue Set CID 11 Route Of Administrationdose>doseQuantity0..1SHOULDPQdoseUnit>@@unit0..1SHOULDValue Set CID 82 Units of Measurerate>rateQuantity0..1MAYPQrateUnit>@@unit1..1SHALLValue Set CID 82 Units of Measure>consumable1..1SHALL>>manufacturedProduct1..1SHALLCD>>@@classCode1..1SHALLSHALLMANU>>>manufacturedMaterial1..1SHALLcodedProductName>>>>code1..1SHALLCEfreeTextProductName>>>>>original Text0..1SHOULDEDBusiness Name aliasThis template defines a primary scoping business name “proceduralMedication” and an alias “Contrast”. This allows production logic to use either term, although the structure is identical. substanceAdministration/@IDThe substanceAdministration entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template.text/reference and Related Narrative Block MarkupThe substanceAdministration entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.doseQuantityPre-coordinated consumable: If the consumable code is a precoordinated unit dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet").Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration.Figure SEQ Figure \* ARABIC 47: Procedural Medication activity example<substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <text> <reference value="#med1/> Proventil 0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing (???CHANGE TO DI EXAMPLE?) </text> <statusCode code="completed"/> <routeCode code="C38216" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="RESPIRATORY (INHALATION)"/> <doseQuantity value="1"/> <rateQuantity value="90" unit="ml/min"/> <consumable> <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id/> <manufacturedMaterial> <code code="329498" codeSystem="2.16.840.1.113883.6.88" displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"> <originalText> <reference value="#manmat1"/> </originalText> <translation code="573621" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Proventil 0.09 MG/ACTUAT inhalant solution"/> </code> </manufacturedMaterial> <manufacturerOrganization>...</manufacturerOrganization> </manufacturedProduct> </consumable></substanceAdministration>observationMediaTemplate ID 1.3.6.1.4.1.19376.1.4.1.4.7NameobservationMedia EntryEffective Date2011-07Version LabelIHECIRC-TIStatusDraft (will change to Approved on Final Text adoption)Description The observationMedia Entry provides an in-line graphic depiction of the section findings. It is referenced by a <renderMultiMedia> element in the section text. Typical uses are for graphic representation of findings (e.g., arterial tree diagrams) or in-line representations of key images.ClassificationCDA Entry LevelRelationships ContextOpen/ClosedOpenRevision History From IHE Cardiac Imaging Report Content Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateobservationMedia[*]observationMedia1..1SHALL@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALLUID1.3.6.1.4.1.19376.1.4.1.4.7image>value1..1SHALLEDsee section 6.9.2>@@representation1..1SHALLCSSHALLB64mediaType>@@mediaType1..1SHALLCSCNESTATICValue set ImageMedia TypeimageURI>>reference0..1MAYTELobservationMedia/@ID and Related Narrative Block MarkupThe ObservationMedia entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) used as a target of a <renderMultiMedia> element in the section/text narrative block of the parent section. See Section 9.1.1.3.image and referenceThe value of type ED SHALL contain an in-line encoding of a graphic using base64. The <reference> element, if present, SHALL reference a URI for the same image as included in-line.Imaging Procedure TechniqueTemplate ID 1.2.840.10008.20.x3.x2NameImaging Procedure TechniqueEffective DateVersion LabelDICOM-yyyymmddStatusDescription The Imaging Procedure Technique entry allows the encoding of various parameters of the image acquisition. Other details may be found in other entries (e.g., procedural medication).ClassificationCDA Entry LevelRelationships Invoked by Imaging Procedure Description sectionContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial versionBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateprocedureTechniqueprocedure1..1SHALL>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x3.x2>id1..*SHALLIIprocedureCode>code1..1SHALLCDeffectiveTime>effectiveTime0..1SHOULDTS methodCode>methodCode0..*MAYCDmodality>methodCode1..1SHALLCDSHALL CNEValue Set CID 29 Acquisition ModalitytargetSite>targetSiteCode0..1SHOULDCDConcept Domain targetSite>>qualifier0..1COND>>>name1..1SHALLCDSHALL(272741003, SNOMED, “laterality”)laterality>>>value1..1SHALLCDSHALL CNEValue Set CID 244 Lateralityref>>reference1..1SHALLURL (XML IDREF)#contentRef>participation0..1COND>@@typecode1..1SHALLCSSHALLLOC>>participantRole1..1SHALL>>@classCode1..1SHALLCSSHALLSDLOC>>>scopingEntity1..1SHALLproviderOrganization>>>>desc1..1SHALLSTidprocedure/id does not correspond to any DICOM UID, but is an arbitrary identifier for this entry.codeWhen invoked from the Current Imaging Procedure Description section, procedure/code SHALL be identical to documentationOf/serviceEvent/code in the CDA header.methodCode - modalityWhen invoked from the Current Imaging Procedure Description section, procedure/methodCode used for modality SHALL be identical to documentationOf/serviceEvent/code/translation used for modality in the CDA header. methodCode – other parametersmethodCode may be used to encode study type, contrast use, challenge, views , positioning (CID 91-94), etc.targetSiteCode and lateralityprocedure/targetSiteCode may be used to encode the specific anatomic focus, and is not necessarily identical to documentationOf/serviceEvent/code/translation used for anatomic region in the CDA header.COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part.text/reference and Related Narrative Block MarkupThe Procedure entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.participation - locationCOND: If this template is invoked from the Comparison Study section, procedure/participation MAY be used to identify the location (provider organization) at which the Comparison Study was performed.Figure SEQ Figure \* ARABIC 48: Procedure Technique template example<procedure moodCode="EVN" classCode="PROC"> <templateId root="1.2.840.10008.20.x3.x2"/> <id root="1.2.840.6544.33.9100653988998717.997527582345600170"/> <procedureCode code="70548" displayName="Magnetic resonance angiography, head; with contrast material(s)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/> <effectiveTime value="20060823222400"/> <methodCode code="MR" displayName="Magnetic Resonance” codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/> <targetSiteCode code="56322004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left PDA"> <qualifier> <value code="40415009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="proximal" /> </qualifier> </targetSiteCode> <targetSiteCode code="56322004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left PDA"> <qualifier> <value code="255562008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="mid" /> </qualifier> </targetSiteCode></procedure>Quantity Measurement Template ID 1.2.840.10008.20.x3.x3NameQuantity MeasurementEffective DateVersion LabelDICOM-yyyymmddStatusDescription A Quantity Measurement records quantitative measurements such as linear, area, volume, and numeric measurements. If based on image data, a reference to the image may be present.ClassificationCDA Entry LevelRelationships ContextOpen/ClosedopenRevision HistoryDICOM-yyyymmdd: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.14. This derivation includes required XML ID; Units of Measure specified with DICOM value set for UCUM (CID 82 Units of Measure), equivalent to C-CDA specified value set (UCUM Units of Measure (case sensitive) 2.16.840.1.113883.11.12839); addition of optional interpretationCode Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateQuantityMeasurement[*]observation1..1SHALL@@ID1..1SHALLXML IDSee xml ID attribute@@moodCode1..1SHALLCSSHALLEVN>templateId1..1SHALLII>@@root1..1SHALLUIDSHALL1.2.840.10008.20.x3.x3>id1..1SHALLIIMeasurementName>code1..1SHALLCDConcept Domain ObservationTypeMeasurementValue>value1..1SHALLPQ>@@xsi:type1..1SHALLSHALLPQMeasurementUnits>@@unit1..1SHALLCSSHALLCNEValue Set CID 82 Units of Measure Time>effectiveTime0..1SHOULDTSInterpretationCode>interpretationCode0..1MAYCESHALL CNEValue Set ObservationInterpretation ActionableFindingCode>>translation1..1SHALLCDSHOULDValue Set CID x7035See interpretationCode and translationTargetSite>targetSiteCode0..1MAYCDConcept Domain ObservationSiteMethod>methodCode0..1MAYCDConcept Domain ObservationMethod>text0..1SHOULDref>>reference1..1SHALLURL (XML IDREF)#contentRef>entryRelationship0..*MAY>@@typeCode1..1SHALLCSSHALLSPRTSOPInstance[*]>>observation1..1SHALLSOP Instance Observation>entryRelationship0..*MAY>@@typeCode1..1SHALLCSSHALLSPRTQuantityMeasurement[*]>observation1..1SHALLQuantity Measurement observation/@ID The QuantityMeasurement observation entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template. text/reference and Related Narrative Block MarkupThe Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element of the Observation class) SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.interpretationCode and translationWhen a measurement is out of normal range, it may be flagged using the interpretationCode. Very abnormal values, often denoted as exceeding “panic limits” or as “actionable”, may have values such as low alert (“LL”), high alert (“HH”), or abnormal alert (“AA”). The translation element of the interpretationCode may be used to provide a further classification as defined in a regionally- or professionally-specified value set. This template identifies an optional value set for the ACR Actionable Finding categories 1, 2, and 3, as defined by: Larson PA, et al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016.Figure SEQ Figure \* ARABIC 49: Quantity measurement observation example<text> ... <content ID="Q21" styleCode="Bold">Calcium score (Agatston): 817 [HIGH – ACR Cat3]</content> ... </text><observation classCode="OBS" moodCode="EVN" ID="Q21a"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <code code="112058" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Calcium score" /> <text><reference value="#Q21"/></text> <statusCode code="completed"/> <effectiveTime value="20160823223912"/> <value xsi:type="PQ" unit="[arb'U]">817</value> <interpretationCode code="HH" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation" displayName="High alert"> <translation code="RID49482" codeSystem="2.16.840.1.113883.6.256" codeSystemName="RADLEX" displayName="ACR Category 3 Actionable Finding" /> </interpretationCode> <methodCode code="112055" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Agatston" /> <!-- entryRelationships to SOP Instance Observations may go here --></observation>Study ActTemplate ID 1.2.840.10008.20.x3.x5NameStudy ActEffective DateVersion LabelDICOM-yyyymmddStatusDescription A Study Act contains the DICOM study information that defines the characteristics of a referenced medical study performed on a patient. A study is a collection of one or more series of medical images, presentation states, SR documents, overlays, and/or curves that are logically related for the purpose of diagnosing a patient. Each study is associated with exactly one patient. A study may include composite instances that are created by a single modality, multiple modalities, or by multiple devices of the same modality. The study information is modality-independent. ClassificationCDA Entry LevelRelationships Used By: DICOM Object Catalog and Comparison StudyContextOpen/ClosedOpenRevision HistoryDICOM-yyyymmdd: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.6. This derivation includes required XML ID, makes Series conditional (required for Object Catalog) to support use in Comparison Study reference.Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateStudy[*]act1..1SHALL@@classCode1..1SHALLCSACT@@moodCode1..1SHALLCSEVN@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALL1.2.840.10008.20.x3.x5>id1..1SHALLIIStudyUID>@@root1..1SHALLUIDStudy Instance UID (0020,000D)>@@extension0..0SHALL NOT>code1..1SHALLCD(113014, DCM, "Study") Description>text0..1MAYEDTime>effectiveTime0..1SHOULDTS Study Date (0008,0020) and Study Time (0008,0030)>entryRelationship1..*COND>@@typeCode1..1SHALLCSCOMPSeries[*]>>actSeries Actact/@IDThe act entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template.Note:The DICOM Study ID (0020,0010) attribute value, if it conforms to the XML Name production requirements, may be used as the ID.entryRelationship/act - seriesCOND: If this template is invoked by the DICOM Object Catalog, the entryrelationship to the Series act SHALL be present, otherwise it MAY be present. Figure SEQ Figure \* ARABIC 50: Study act example<act classCode="ACT" moodCode="EVN" ID="S90051051"> <templateId root="2.16.840.1.113883.10.20.6.2.6"/> <id root="1.2.840.113619.2.62.994044785528.114289542805"/> <code code="113014" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Study"/> <effectiveTime value="20060823223232"> <!-- **** Series ****--> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> ... </act> </entryRelationship></act>Series ActTemplate ID 1.2.840.10008.20.x3.x6NameSeries ActEffective DateVersion LabelCCDA-1StatusApprovedDescription A Series Act contains the DICOM series information for referenced DICOM composite objects. The series information defines the attributes that are used to group composite instances into distinct logical sets. Each series is associated with exactly one study. Series Act clinical statements are only instantiated in the DICOM Object Catalog section inside a Study Act, and thus do not require a separate templateId; in other sections, the SOP Instance Observation is included directly.ClassificationCDA Entry LevelRelationships Used By: Study ActContextOpen/ClosedopenRevision HistoryDICOM-yyyymmdd: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.22.4.63. This derivation includes required XML ID.Business NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateSeries[*]act1..1SHALL@@classCode1..1SHALLCSACT@@moodCode1..1SHALLCSEVN@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x3.x6>id1..1SHALL>@@root1..1SHALLUIDSeries Instance UID (0020,000E)>@@extension0..0SHALL NOT>code1..1SHALLCD(113015, DCM, “Series” )>>qualifier1..1SHALL>>>name1..1SHALLCD(121139, DCM, “Modality”) Modality>>>value1..1SHALLCDModality (0008,0060)Description>text0..1MAYEDTime>effectiveTime0..1SHOULDTS Series Date (0008,0021) and Series Time (0008,0031)>entryRelationship1..*SHALL>@@typeCode1..1SHALLCSCOMPSOPInstance[*]>>observation1..1SOP Instance Observationact/@IDThe act entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template.Figure SEQ Figure \* ARABIC 51: Series act example<act classCode="ACT" moodCode="EVN" ID="Series01"> <id root="1.2.840.113619.2.62.994044785528.20060823223142485051"/> <code code="113015" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Series"> <qualifier> <name code="121139" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Modality"> </name> <value code="CR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Computed Radiography"> </value> </qualifier> </code> <!-- **** SOP Instance UID *** --> <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/> ... </observation> </entryRelationship></act>SOP Instance ObservationTemplate ID 1.2.840.10008.20.x3.x7NameSOP Instance ObservationEffective DateVersion LabelDICOM-yyyymmddStatusDescription A SOP Instance Observation contains the DICOM Service Object Pair (SOP) Instance information for referenced DICOM composite objects. The SOP Instance act class is used to reference both image and non-image DICOM instances. The text attribute contains the DICOM WADO reference.ClassificationCDA Entry LevelRelationships ContextOpen/ClosedopenRevision HistoryDICOM-yyyymmdd: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.8This derivation includes required XML ID; Purpose of Reference value set specified with DICOM CID 7003; directly incorporates descendant templates Purpose of Reference Observation, Referenced Frames, and Boundary ObservationBusiness NameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateSOPInstance[*]observation1..1SHALL@@classCode1..1SHALLCSDGIMG@@moodCode1..1SHALLCSEVN@@ID1..1SHALLXML IDSee xml ID attribute>templateId1..1SHALLII>@@root1..1SHALLUID1.2.840.10008.20.x3.x7SOPInstanceUID>id1..*SHALLIISOP Instance UID (0008,0018)>code1..1SHALLCDSOPClassUID>@@code1..1SHALLSTSOP Class UID (0008,0016)>@@codeSystem1..1SHALLUIDSHALL1.2.840.10008.2.6.1>text0..1SHOULDED>@@mediaType1..1SHALLSTSHALLapplication/dicomWADOReference>>reference1..1SHALLURL>effectiveTime0..1SHOULDTS >entryRelationship0..*COND>@@typeCode1..1SHALLCSSHALLSUBJSOPInstance[*]>>observation1..1SHALLSOP Instance Observation>entryRelationship0..1COND>@@typeCode1..1SHALLCSSHALLRSON>>observation1..1SHALL>>@@classCode1..1SHALLCSOBS>>@@moodCode1..1SHALLCSEVN>>>code1..1SHALLCDSHALL(ASSERTION, ActCode (2.16.840.1.113883.5.4), "Assertion")PurposeOfReference>>>value1..1SHALLCDSHALLCWEDYNAMICValue set CID 7003 Diagnostic Imaging Report Purposes of Reference>entryRelationship0..1COND>@@typeCode1..1SHALLCSSHALLCOMP>>observation1..1SHALL>>@@classCode1..1SHALLCSROIBND>>@@moodCode1..1SHALLCSEVN>>code1..1SHALLCDSHALL(121190, DCM, "Referenced Frames") >>entryRelationship1..1SHALL>>@@typeCode1..1SHALLCSSHALLCOMP>>>observation1..1SHALL>>>@@classCode1..1SHALLCSOBS>>>@@moodCode1..1SHALLCSEVN>>>code1..1SHALLCDSHALL(113036, DCM, "Frames for Display") ReferencedFrames>>>value1..1SHALLLIST<INT>observation/@IDThe observation entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) that serves as the business name discriminator associated with an instantiation of the template.entryRelationshipCOND: entryRelationship SHALL NOT be present in a SOP Instance Observation included within a DICOM Object Catalog section, and MAY be present otherwise.entryRelationship/@typeCode=SUBJ (SOP Instance)This template recursively invokes itself to allow a Presentation State SOP Instance reference to identify the target Image SOP Instances. Note: This is not required, as the Presentation State SOP Instance itself identifies the target Image SOP Instances.entryRelationship/@typeCode=RSON (Purpose of Reference)A Purpose of Reference Observation describes the purpose of the DICOM composite object reference. Appropriate codes, such as externally defined DICOM codes, may be used to specify the semantics of the purpose of reference. When this observation is absent, it implies that the reason for the reference is unknown.Note:In Consolidated CDA r1.1, this was defined using a separate “Purpose of Reference Observation” template, which is included directly in this template specification.entryRelationship/@typeCode=COMP (Referenced Frames)A Referenced Frames Observation contains a list of integer values for the referenced frames of a DICOM multiframe image SOP instance. It identifies the frame numbers within the referenced SOP instance to which the reference applies. The observation identifies frames using the same convention as DICOM, with the first frame in the referenced object being Frame 1. A Referenced Frames Observation must be used if a referenced DICOM SOP instance is a multiframe image and the reference does not apply to all frames.Note:In Consolidated CDA r1.1, this was defined using separate “Referenced Frames Observation” and “Boundary Observation” templates, which are included directly in this template specification.Figure SEQ Figure \* ARABIC 52: Purpose of reference example<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.9"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <value xsi:type="CD" code="121112" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Source of Measurement"/></observation>Figure SEQ Figure \* ARABIC 53: SOP instance observation example<observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/> <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/> <code code="1.2.840.10008.5.1.4.1.1.1" codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID" displayName="Computed Radiography Image Storage"> </code> <text mediaType="application/dicom"> <reference value=""/> <!--reference to image 1 (PA) --> </text> <effectiveTime value="20060823223232"/></observation>Image Quality Template ID 1.2.840.10008.20.x3.x4NameImage QualityEffective DateVersion LabelDICOM-yyyymmddStatusDescription Provides a quality assessment for the image set identified by the invoking section. By default unless otherwise identified, applies to the image set interpreted by the document (typically a Study). If the quality rating applies to only a subset of the Study (e.g., a Series, or a specific Image), that subset shall be identified in the invoking section.ClassificationCDA Entry LevelRelationships ContextOpen/ClosedopenRevision HistoryDICOM-yyyymmdd: Initial version Derived from Coded ObservationNameNest LevelElement/ AttributeCardElem/ Attr ConfData TypeValue ConfValue Subsidiary TemplateImageQualityobservation1..1SHALL@@moodCode1..1SHALLCSSHALLEVN>templateId1..1SHALLII>@@root1..1SHALLUIDSHALL1.2.840.10008.20.x3.x4>id1..1SHALLII>code1..1SHALLCD(111050, DCM, "Image Quality Assessment")rating>value1..1SHALLCDSHOULD CWEValue Set CID x7036 Image Quality Assessment>@@xsi:type1..1SHALLSHALLCE>text0..1SHOULDref>>reference1..1SHALLURL (XML IDREF)#contentReftext/reference and Related Narrative Block MarkupThe Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element of the Observation class) SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.Mapping DICOM SR to CDAEquivalent of current Part 20 Annex A – work in progress!CDA Business NameDICOM SRImagingReport: DocTypeImagingReport: documentIDImagingReport: titleCode Meaning (0008,0104) of "Equivalent Meaning of Concept Name" (TID 1210) if code is available. If code is not present: Code Meaning (0008,0104) of Concept name code sequence (0040,A043) of the root content item. .ImagingReport: creationTimeContent Date (0008,0023), Content Time (0008,0033) of the SR Document General ModuleImagingReport: confidentialityImagingReport: languageCodeCode Sequence (0040,A043) of "Language of Content Item and Descendants" code content item (TID 1204): <code value as code property, coding scheme designator as codeSystemName property, code meaning as displayName property> (as defined by the IETF (Internet Engineering Task Force) RFC 3066)ImagingReport: setIdImagingReport: versionNumberImagingReport: Patient:IDImagingReport: Patient:AddrImagingReport: Patient:TeleImagingReport: Patient:NameImagingReport: Patient:GenderImagingReport: Patient:BirthTimeImagingReport: Patient:providerOrgNameImagingReport: Patient:providerOrgTelImagingReport: Patient:providerOrgAddrImagingReport: SigningTimeVerification DateTime (0040,A030) within Verifying Observer Sequence.ImagingReport: SignerIDVerifying Observer Identification Code Sequence (0040,A088): code value as identifierImagingReport: SignerAddrImagingReport: SignerTelImagingReport: SignerNameVerifying Observer Name (0040,A075) within Verifying Observer SequenceImagingReport: AuthorIDImagingReport: AuthorAddrImagingReport: AuthorTelImagingReport: AuthorNameImagingReport: CustodianOrgIDImagingReport: CustodianOrgNameImagingReport: CustodianOrgAddrImagingReport: CustodianOrgTelImagingReport: encounterIDAdmission Id (0038,0010) and Issuer of Admission ID Sequence (0038;0014) of the Patient Study ModuleImagingReport: encounterTimeImagingReport: HealthcareFacilityNameImagingReport: HealthcareFacilityAddressImagingReport: HealthcareProviderOrganizationNameImagingReport: AttendingPhysicianNamePhysician(s) of Record (0008,1048)ImagingReport: OrderPlacerNumber@extension = TEXT Value where Concept Code = (121021, DCM, "FillerNumber") @root = TEXT where (110190, DCM, "Issuer of Identifier") as CONCEPT MOD to (121021, DCM, "FillerNumber")ImagingReport: OrderFilllerNumberImagingReport: AccessionNumberImagingReport: OrderedCodeRequested Procedure Code Sequence (0032,1064) within the Referenced Request Sequence (0040,A370)ImagingReport: OrderPriorityImagingReport: ProcedureCodeImagingReport: ModalityCodeImagingReport: AnatomicRegionCodeImagingReport: ProcedureTimeImagingReport: Performer IDImagingReport: PerformerNameImagingReport: ReferrerAddrPerson's Address (0040,1102) of Referring Physician Identification Sequence (0008,0096): DICOM ST (Short Text) String Data TypeImagingReport: ReferrerTelPerson's Telephone Numbers (0040,1103) of Referring Physician Identification Sequence (0008,0096): DICOM LO (Long String) String Data TypeImagingReport: ReferrerNameReferring Physician's Name (0008,0090)ImagingReport: TranscriptionistIDPerson Identification Code Sequence (0040,1101) within Participant Sequence (0040,A07A) where Participation Type (0040,A080) equals "ENT" (Data Enterer): code value as identifierImagingReport: TranscriptionistNamePerson Name (0040,A123) of Participant Sequence (0040,A07A) where Participation Type (0040,A080) equals "ENT" (Data Enterer).ImagingReport: TransformedDocumentIDSOP Instance UID (0008,0018) of original DICOM SR Composite Object. DICOM Template 2000 specifies that Imaging Report Elements of Value Type Code are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Coded DICOM Imaging Report Elements in this context are mapped to CDA-coded observations that are section entries and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.PS3.6 – Data DictionaryA Registry of DICOM Unique Identifiers (UIDs) (Normative)Table?A-3.?Context Group UID ValuesContext UIDContext IdentifierContext Group Name1.2.840.10008.6.?1.?x1x7021 Imaging Report Document Titles1.2.840.10008.6.?1.?x2x7035Actionable Finding Classification1.2.840.10008.6.?1.?x4x10040Summary Radiation Exposure QuantitiesTable?A-4.?Template UID ValuesUID ValueUID NameUID TypePart1.2.840.10008.?20.x1.x1Imaging ReportDocument TemplateIDPS3.201.2.840.10008.20.x2.x1Clinical InformationSection TemplateIDPS3.201.2.840.10008.20.x2.x2Imaging Procedure DescriptionSection TemplateIDPS3.201.2.840.10008.20.x2.x3Comparison StudySection TemplateIDPS3.201.2.840.10008.20.x2.x4ImpressionSection TemplateIDPS3.201.2.840.10008.20.x2.x5AddendumSection TemplateIDPS3.201.2.840.10008.20.x2.x6RequestSection TemplateIDPS3.201.2.840.10008.20.x2.x7Radiation Exposure and Protection InformationSection TemplateIDPS3.201.2.840.10008.20.x2.x8OBUS Fetus FindingsSection TemplateIDPS3.201.2.840.10008.20.x2.x9Labeled SubsectionSection TemplateIDPS3.201.2.840.10008.20.x2.x10Communication of Actionable FindingsSection TemplateIDPS3.201.2.840.10008.20.x2.x11Study RecommendationSection TemplateIDPS3.201.2.840.10008.20.x2.x12Procedure IndicationsSection TemplateIDPS3.201.2.840.10008.20.x3.x1Procedural MedicationEntry TemplateIDPS3.201.2.840.10008.20.x3.x2Imaging Procedure TechniqueEntry TemplateIDPS3.201.2.840.10008.20.x3.x3Quantity MeasurementEntry TemplateIDPS3.201.2.840.10008.20.x3.x4Image QualityEntry TemplateIDPS3.201.2.840.10008.20.x3.x5Study ActEntry TemplateIDPS3.201.2.840.10008.20.x3.x6Series ActEntry TemplateIDPS3.201.2.840.10008.20.x3.x7SOP Instance ObservationEntry TemplateIDPS3.201.2.840.10008.20.x4.x0Section TextElement Set TemplateIDPS3.201.2.840.10008.20.x4.x1General Header ElementsElement Set TemplateIDPS3.201.2.840.10008.20.x4.x2Imaging Header ElementsElement Set TemplateIDPS3.201.2.840.10008.20.x4.x3Parent Document Header ElementsElement Set TemplateIDPS3.201.2.840.10008.20.x4.x4General Section EntriesElement Set TemplateIDPS3.20 PS3.16 - Content Mapping ResourceCoding SchemesTable?8-1 lists the coding schemes (and their designators) defined for use in DICOM; Table 8-2 lists the HL7v3 coding schemes referenced for use in DICOM. …Table?8-1.?Coding SchemesCoding Scheme DesignatorCoding Scheme UIDDescription…RFC30662.16.840.1.113883.6.121RFC 3066, Tags for the Identification of Languages, Internet Engineering Task ForceNoteHL7 uses "IETF3066" for the symbolic name.RFC3066 has been superseded by RFC4646.IETF4646RFC 4646, Tags for Identifying Languages, The Internet Society (2005)Table?8-2.?HL7v3 Coding SchemesCoding Scheme DesignatorCoding Scheme UIDDescriptionActCode2.16.840.1.113883.5.4ActPriority2.16.840.1.113883.5.7AdministrativeGender 2.16.840.1.113883.5.1mediaType2.16.840.1.113883.5.79RFC2046NullFlavor2.16.840.1.113883.5.1008ObservationInterpretation2.16.840.1.113883.5.83Confidentiality2.16.840.1.113883.5.25ParticipationType 2.16.840.1.113883.5.90DCMR Context Groups (Normative)Green indicates “For reference only” (no changes)CID 11?Route of AdministrationType:ExtensibleVersion:20100608Table CID 11. Route of AdministrationCoding Scheme DesignatorCode ValueCode MeaningSRTG-D101Intravenous routeSRTG-D102Intra-arterial routeSRTG-D103Intramuscular route…CID 25?RadiopharmaceuticalsType:ExtensibleVersion:20110224Table CID 25. RadiopharmaceuticalsCoding Scheme DesignatorCode ValueCode MeaningSRTC-B1302Carbon^14^ D-xyloseSRTC-B1300Carbon^14^ trioleinSRTC-B1304Cholyl-carbon^14^ glycine…CID 29?Acquisition ModalityThis Context Group includes codes that may be used to identify an image or waveform acquisition modality, as used in Attribute Modality (0008,0060) of a Modality Worklist Scheduled Procedure Step or a Composite SOP Instance (see PS3.3). It generally corresponds to a class of diagnostic equipment, or to a specific acquisition function or technique in a device. This Context Group may be used as the value set for HL7 v2 Table 0259 (see HL7 v2.6 Chapter 8 Section 8.8.8.47).NoteThis Context Group is not the complete set of codes that may appear in the Attribute Modality (0008,0060); these are only the codes associated with orderable acquisition processes (not post-processing).Type:ExtensibleVersion:20121129Table CID 29. Acquisition ModalityCoding Scheme DesignatorCode ValueCode MeaningDCMARAutorefractionDCMBMDBone Mineral DensitometryDCMBDUSUltrasound Bone Densitometry…CID 82 Units of MeasurementNot defined as a table of codes per se, but rather constructed from UCUM. Context Group ID 82 comprises the case-sensitive codes of UCUM. See Section 7.2.2. Note:1. Equivalent to the HL7 Value Set “Units of Measure case sensitive” 2.16.840.1.113883.11.12839CID 244 LateralityType:Non-ExtensibleVersion:20030108Table?CID 244.?LateralityCoding Scheme DesignatorCode ValueCode MeaningSNOMED-CT Concept IDUMLS Concept Unique IDSRTG-A100Right24028007C0205090SRTG-A101Left7771000C0205091SRTG-A102Right and left51440002C0238767SRTG-A103Unilateral66459002C0205092CID 4021?PET RadiopharmaceuticalsType:ExtensibleVersion:20130207Table CID 4021. PET RadiopharmaceuticalsCoding Scheme DesignatorCode ValueCode MeaningSRTC-B1043Acetate C^11^SRTC-B103CAmmonia N^13^SRTC-B07DBATSM Cu^64^…CID 5000?LanguagesContext Group ID 5000 comprises the language tag coding scheme of RFC 30664646. The Coding Scheme Designator (0008,0102) shall be RFC3066IETF4646.NoteThe RFC 30664646 coding scheme is constructed from a primary subtag component encoded using the language codes of ISO 639, plus two codes for extensions for languages not represented in ISO 639. The code optionally includes a second additional subtag components, for scripts encoded using the four letter codes of ISO 15924, and for regions encoded using the two letter country codes of ISO 3166, or a language code extension registered by the Internet Assigned Names Authority.RFC 30664646 may be obtained at . RFC 30664646 obsoletes RFC 3066 and RFC 1766, but is forward compatible with those specifications.ISO 639 codes may be obtained at two letter country codes of ISO 3166 may be obtained at language tag registrations may be obtained at previous editions of the Standard, this Context Group formerly included the three letter language codes of ISO 639-2/B, using Coding Scheme Designator ISO639_2, or the langue codes of RFC 3066, using Coding Scheme Designator RFC3066, and several IANA-registered language code extensions, using Coding Scheme Designator IANARFC1766. RFC 3066 identifies a preference for the ISO 639-1 two letter codes to the ISO 639-2 three letter codes, and the ISO 639-2/T (terminology) subset to the ISO 639-2/B (bibliographic) subset.In previous editions of the Standard, this Context Group provided only language identifiers, with national or regional variant identified in a separate attribute or Content Item.CID 6096 Pregnancy StatusType:ExtensibleVersion:20040112Table?CID 6096.?Pregnancy StatusCoding Scheme DesignatorCode ValueCode MeaningSNOMED CT Concept ID EquivalentSRTF-81890not pregnant60001007SRTF-84094possible pregnancy102874004SRTF-84000patient currently pregnant77386006SRTR-41198Unknown261665006CID 7003?Diagnostic Imaging Report Purposes of ReferenceType:ExtensibleVersion:20100604Table?CID 7003.?Diagnostic Imaging Report Purposes of ReferenceCoding Scheme DesignatorCode ValueCode MeaningDCM121079BaselineDCM121080Best illustration of findingDCM121112Source of MeasurementDCM121200Illustration of ROICID x7021? Imaging Report Document TitlesType:ExtensibleVersion:yyyymmddTable?CID x7021.?Imaging Report Document TitlesCoding Scheme DesignatorCode ValueCode MeaningLOINC 18748-4Diagnostic Imaging ReportLOINC 75238-6Interventional radiology procedure noteLOINC 18747-6CT ReportLOINC 18755-9MRI ReportLOINC 18760-9Ultrasound ReportLOINC 18757-5Nuclear Medicine ReportLOINC 17787-3Thyroid Scan ReportLOINC 18758-3PET Scan ReportLOINC 11525-3Obstetrical Ultrasound ReportLOINC 43468-8Radiography ReportLOINC 49512-7Fluoroscopy ReportLOINC30639-9Fluoroscopic Angiography ReportLOINC 24606-6Mammography Screening ReportLOINC 24605-8 Diagnostic Mammography ReportLOINC 38269-7Bone Density ReportCID x7035? Actionable Finding ClassificationType:ExtensibleVersion:yyyymmddTable?CID x7035. Actionable Finding ClassificationCoding Scheme DesignatorCode ValueCode MeaningRADLEXRID49480ACR Category 1 Actionable FindingRADLEXRID49481ACR Category 2 Actionable FindingRADLEXRID49482ACR Category 3 Actionable FindingCID x7036? Image Quality AssessmentType:ExtensibleVersion:yyyymmddTable?CID x7036. Image Quality AssessmentCoding Scheme DesignatorCode ValueCode MeaningRADLEXRID12Diagnostic qualityRADLEXRID13Limited qualityRADLEXRID14Non-diagnostic qualityCID x10040? Summary Radiaion Exposure QuantitiesType:ExtensibleVersion:yyyymmddTable?CID x10040.?Summary Radiation Exposure QuantitiesCoding Scheme DesignatorCodeCode Meaning DCM111637Accumulated Average Glandular Dose (mammo)DCM113830Mean CTDIvolDCM113813CT Dose Length Product TotalDCM113722Dose Area Product TotalDICOM Controlled Terminology Definitions (Normative)Code ValueCode MeaningDefinitionNotes99SUP155-1Patient exposure to ionizing radiationPatient exposure to ionizing radiation (procedure)99SUP155-5Results communicatedThe act of communicating actionable findings to a responsible receiverExternally defined Value SetsThis annex identifies those Value Sets defined externally to the DICOM Standard that are referenced by the Standard. These value sets are reproduced here for reference only, and may not be the current version. These value sets use codes from various coding schemes or code systems, as identified in Section 8.HL7 Value Sets are reproduced with the permission of HL7 International.Value Set NameOIDNotesActPriority2.16.840.1.113883.11.16866AdministrativeGender 2.16.840.1.113883.11.1HumanLanguages2.16.840.1.113883.11.11526Equivalent to CID 5000ImageMediaType 2.16.840.1.113883.11.14839NullFlavor2.16.840.1.113883.11.10609ObservationInterpretation 2.16.840.1.113883.11.78x_BasicConfidentialityKind2.16.840.1.113883.11.16926x_serviceEventPerformer2.16.840.1.113883.11.19601ActPriority Value SetValue Set: ActPriority 2.16.840.1.113883.11.16866 DYNAMICCode System(s):ActPriority 2.16.840.1.113883.5.7CodeCode SystemPrint NameAActPriorityASAPCRActPriorityCallback resultsCSActPriorityCallback for schedulingCSPActPriorityCallback placer for schedulingCSRActPriorityContact recipient for schedulingELActPriorityElectiveEMActPriorityEmergencyPActPriorityPreoperativePRNActPriorityAs neededRActPriorityRoutineRRActPriorityRush reportingSActPriorityStatTActPriorityTiming criticalUDActPriorityUse as directedURActPriorityUrgentAdministrativeGender Value SetValue Set: AdministrativeGender 2.16.840.1.113883.11.1 DYNAMICCode System(s): AdministrativeGender 2.16.840.1.113883.5.1CodeCode SystemPrint NameFAdministrativeGenderFemaleMAdministrativeGenderMaleUNAdministrativeGenderUndifferentiatedImageMediaType Value SetValue Set: HL7 ImageMediaType 2.16.840.1.113883.11.14839 DYNAMICCode System(s): mediaType 2.16.840.1.113883.5.79CodeCode SystemPrint Nameimage/g3faxmediaTypeg3faximage/gifmediaType gifimage/jpegmediaType jpegimage/pngmediaType pngimage/tiffmediaType tiffNullFlavor Value SetValue Set: HL7 NullFlavor 2.16.840.1.113883.11.10609 DYNAMICCode System(s): NullFlavor 2.16.840.1.113883.5.1008CodeCode SystemPrint NameNINullFlavor No InformationOTHNullFlavor otherNINFNullFlavor negative infinityPINFNullFlavor positive infinityUNKNullFlavor unknownASKUNullFlavor asked but unknownNAVNullFlavor temporarily unavailableNASKNullFlavor not askedTRCNullFlavor traceMSKNullFlavor maskedNANullFlavor not applicableNPNullFlavor not presentObservationInterpretation Value SetValue Set: HL7 ObservationInterpretation 2.16.840.1.113883.11.78 DYNAMICCode System(s): ObservationInterpretation 2.16.840.1.113883.5.83CodeCode SystemPrint NameBObservationInterpretation betterDObservationInterpretation decreasedUObservationInterpretation increasedWObservationInterpretation worse<ObservationInterpretation low off scale>ObservationInterpretation high off scaleAObservationInterpretation AbnormalAAObservationInterpretation Abnormal alertHHObservationInterpretation High alertLLObservationInterpretation Low alertHObservationInterpretation HighLObservationInterpretation LowNObservationInterpretation NormalIObservationInterpretation intermediateMSObservationInterpretation moderately susceptibleRObservationInterpretation resistentSObservationInterpretation susceptibleVSObservationInterpretation very susceptiblex_ BasicConfidentialityKind Value SetValue Set: x_ BasicConfidentialityKind 2.16.840.1.113883.11.16926 STATIC 2010-04-21Code System(s):Confidentiality 2.16.840.1.113883.5.25CodeCode SystemPrint NameN Confidentiality NormalRConfidentiality Restricted VConfidentiality Very Restricted x_serviceEventPerformer Value SetValue Set: HL7 x_serviceEventPerformer 2.16.840.1.113883.11.19601 DYNAMICCode System(s): ParticipationType 2.16.840.1.113883.5.90CodeCode SystemPrint NamePRF ParticipationTypePerformerPPRF ParticipationTypePrincipal performerSPRF ParticipationTypeSecondary performer ................
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