Supplement 127: CT Radiation Dose Reporting (Dose SR)



Digital Imaging and Communications in Medicine (DICOM)

Supplement nnn: National Radiology Report

Prepared by: WG-20

DICOM Standards Committee, Working Group 6, Base Standard

1300 N. 17th Street, Suite 1847

Rosslyn, Virginia 22209 USA

Version: Public Comment

JulyApril 212, 2008

Table of Contents

Document History 3

Open Issues and Work To Do 3

Foreword 4

Scope and Field of Application 4

Changes to NEMA Standards Publication PS 3.16-2007 5

Item #02: Add new Section to Annex A 6

NATIONAL RADIOLOGY REPORT TEMPLATES 6

TID xxxx1 National Radiology Report 6

TID xxxx2 Examination 7

TID xxxx3 Medical Content 8

TID xxxx4 Radiology Report Section Content 9

TID xxxx5 German Extension 9

TID xxxx6 Information concerning the German X-Ray and Radiation Control Regulation 9

Item #4: Add the following Definitions to Annex D 10

Item #5: Extend the Context ID 7001 11

Item #7: Add a new Annex 11

Document History 3

Open Issues and Work To Do 3

Foreword 3

Scope and Field of Application 4

Changes to NEMA Standards Publication PS 3.16-2007 5

Item #02: Add new Section to Annex A 6

NATIONAL RADIOLOGY REPORT TEMPLATES 6

TID xx03 Examination 7

TID xx04 Medical Content 7

TID xx08 German Extension 8

TID xx01 Information concerning the German X-Ray Regulation 8

TID xx02 Information concerning the German Radiation Control Regulation 9

Item #4: Add the following Definitions to Annex D 10

Item #5: Extend the Context ID 7001 10

Item #6: Extend the Context ID 7002 11

Item #7: Add a new Annex 12

Document History

|Version |Date |Comments |

|01 |July 11, 2007 |Created, draft distributed |

|02 |November 15, 2007 |Changes to PS 3.3 removed |

|03 |November 30, 2007 |Includes changes as result of the tecon November 20, 2007 |

|04 |January 3, 2008 |Included tem,plate TID xx06 into template TID Tx10011 to make the overall base-structure |

| | |of TID 2000 more clear. |

| | |Added a remark to row 7 of template TID xx01. |

| | |Acepted all changes made so far. |

|05 |April 2, 2008 |Reference to Radiation Dose Report added in Examination Section. |

|06 |June 12, 2008 |- Level of identation changed in TID xx01 and TID xx02 |

| | |- Target region in TID xx03 may be included as text or code content item |

| | |- Modified TID xx06 “Radiology Report Section Content” for reuse of section content |

| | |(identical to TID 2000 section content) |

| | |- TID xx01 and TID xx02 have been merged into single template TID xx01 that may contain |

| | |information required by the German X-Ray or Radiation Control Regulation |

|07 |July 21, 2008 |- Template overview diagram has been added |

| | |- New templates and new codes have been renumbered |

| | |- Changed TID xxxx5 “German Extension” to extensible |

| | |- Mandatory information on “Performing Physician” and/or “Performing Technologist” will be|

| | |provided as part of the observer context in the root template |

Open Issues and Work To Do

|# |Issue |To Do |

|1 |Clarification needed if new context groups are needed for participants and observations | |

| |that are part of the German extensions.The templates for the National Radiology Report | |

| |contain DATE and PNAME elements in mandatory fields as well as TIME and UIDREF in user | |

| |option fields. They are not allowed in TID 2000 | |

|2 |Align Performing Person + related organization with HL7 V3 and DICOM Participant Sequence |Clarification needed if new context groups |

| |(0040,A07A) of the SR Document General Module -> Add PERFORMER participation type to DICOM|are needed for participants and |

| |Participant Sequence?Proposed extensions to CID 7002 Diagnostic Imaging Report Elements ->|observations that are part of the German |

| |is the use of report elements for those concepts appropriate? |extensions. |

Foreword

This supplement to the DICOM standard introduces a template for National Radiology Report in DICOM. The concepts of Structured Reporting will be used in this context.

This document is a Supplement to the DICOM Standard. It is an extension to the following parts of the published DICOM Standard:

PS 3.16 Content Mapping Resource

Scope and Field of Application

German law requires written report for X-ray and nuclear medicine examinations.

The German X-Ray and Radiation Control Regulation („Röntgenverordnung“, „Strahlenschutzverordnung“) does not specify the content of the report.

The German national standard DIN 6827-5, „Recording in medical application of ionizing radiation – Part 5: Radiological report“ specifies the medical content of the report and gives the option to document radiation protection content.

„TID 2000 Basic Diagnostic Imaging Report“ defines only the skeletal structure of the report. TID 2000 does not require medical content or content concerning radiation protection.

The objective of this work item is the translation of DIN 6827-5 into a DICOM SR template.

To allow a flexible definition of the content a new template should be defined. The structure of the template should be similar to TID2000.

To avoid discrepancies a close cooperation with WG-20 (Integration of Imaging and Information Systems) is aspired. A first evaluation of the draft gave no principal objections concerning the structure. Codes defined for use in the new template could be registered as external codes in CDA as well.

Changes to NEMA Standards Publication PS 3.16-2007

Digital Imaging and Communications in Medicine (DICOM)

Part 16: Content Mapping Resource

Item #02: Add new Section to Annex A

NATIONAL RADIOLOGY REPORT TEMPLATES

The templates that comprise the National Radiology are interconnected as in Figure X-n:

[pic]

TID xxxx1 National Radiology Report

The National Radiology Report template is used for general diagnostic imaging interpretation reports with country-specific extensions that cover national documentation requirements. It contains the mandatory sections “Examination” and “Medical Content”. These sections and other section headings selected from.CID 7001 may appear only once in the template.

. It expands the TID 2000 template, without violating the constraints or the overall structure of TID 2000.

TID xTxxx10x011

NATIONAL RADIOLOGY REPORT

Type: Non-Extensible

| |NL |Rel with |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | |Parent | | | |Type | | |

| | | |CONTAINER |BCID(7000) Diagnostic Imaging |1 |M | |Root node |

| | | | |Report Document Titles | | | | |

| |> |HAS CONCEPT |CODE |EV (121058,DCM,”Procedure |1-n |U | | |

| | |MOD | |reported”) | | | | |

| |> |HAS CONCEPT |INCLUDE |DTID(1204) Language of Content |1 |M | | |

| | |MOD | |Item and Descendants | | | | |

| |> |HAS CONCEPT |INCLUDE |DTID (1210) Equivalent Meaning |1-n |U | | |

| | |MOD | |of Concept Name | | | | |

| |> |HAS OBS |INCLUDE |DTID(1001) Observation Context |1 |M |Information on at least one of | |

| | |CONTEXT | | | | |the following person observers | |

| | | | | | | |is mandatory: | |

| | | | | | | |1) “Performing Physican” | |

| | | | | | | |2) “Performing Technologist”. | |

| | | | | | | |(For the respective roles all | |

| | | | | | | |person observer identifying | |

| | | | | | | |attributes of TID 1003 are | |

| | | | | | | |mandatory) | |

| |> |CONTAINS |INCLUDE |DTID(xxxx023) Examination |1 |M | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx304) Medical Content |1 |M | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx508) German Extension |1 |UC |Required for « German Radiology| |

| | | | | | | |Report » | |

| |> |CONTAINS |CONTAINER |BCID(7001) Diagnostic Imaging |1-n |U | |Each heading may appear only |

| | | | |Report Headings | | | |once in the template |

| |>> |CONTAINS HAS |INCLUDE |DTID(xxxx41001) Radiology |1 |U | | |

| | |OBS CONTEXT | |Report Section | | | | |

| | | | |ContentObservation Context | | | | |

| |>> |CONTAINS |CODE |BCID(7002) Diagnostic Imaging |1-n |U | | |

| | | | |Report Elements | | | | |

| |>>> |INFERRED FROM|INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

| |>> |CONTAINS |TEXT |BCID(7002) Diagnostic Imaging |1-n |U | | |

| | | | |Report Elements | | | | |

| |>>> |INFERRED FROM|INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

| |>> |CONTAINS |INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

No content items other than those defined in Observation Context TID 1001 may be the target of a HAS OBS CONTEXT relationship when TID xxxx11001 is invoked.

TID xxxx023 Examination

Contains information related to the examination.

TID xxxx203

EXAMINATION

Type: Non-Extensible

| |NL |Rel with Parent |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | | | | | |Type | | |

| | | |CONTAINER |EV (121064, DCM, |1 |M | | |

| | | | |“Current Procedure | | | | |

| | | | |Descriptions”) | | | | |

| |> |CONTAINS |TEXT |EV (x1004, DCM, |1 |M | | |

| | | | |”Performing Person’s | | | | |

| | | | |Organization Name”) | | | | |

| |> |CONTAINS |TEXT |EV (123014, DCM, |1 |MMC |XOR with Row 4 |CID4028, CID4030, CID4031? |

| | | | |“Target Region“) | | | | |

| |> |CONTAINS |CODE |EV (123014, DCM, |1 |MC |XOR with Row 3 |CID4028, CID4030, CID4031 |

| | | | |“Target Region“) | | | | |

| |> |CONTAINS |TEXT |EV (121065, DCM, |1 |M | | |

| | | | |“Procedure | | | | |

| | | | |Description”) | | | | |

| |> |CONTAINS |DATE |EV (111060, DCM, |1 |M | |Defaults to Study Date |

| | | | |”Study Date”) | | | |(0020,0020) of |

| | | | | | | | |General Study Module |

| |> |CONTAINS |TIME |EV (111061, DCM, |1 |U | |Defaults to Study Time |

| | | | |”Study Time”) | | | |(0020,0030) of |

| | | | | | | | |General Study Module |

| |> |CONTAINS |UIDREF |EV (121018, DCM, |1 |U | |Defaults to Study Instance |

| | | | |“Procedure Study | | | |UID (0020,000D) of |

| | | | |Instance UID”) | | | |General Study Module |

| |> |CONTAINS |COMPOSITE | |1-n |U | |Referenced Radiation Dose |

| | | | | | | | |Reports |

Content Item Descriptions

|Row 5 |The date of the examination. May be different to the Study Date of the General Study IE which reflects the |

| |date of the structured report. |

|Row 6 |The time of the examination. May be different to the Study Time of the General Study IE which reflects the |

| |time of the structured report. |

|Row 7 |The Study Instance UID of the images of the examination. |

|Row 88 |Concept Name is the Root Concept Name (title) of the Radiation Dose Structured Report composite object |

| |instance. |

TID xxxx304 Medical Content

Contains the medical content of the report.

TID xxxx304

MEDICAL CONTENT

Type: Non-Extensible

| |NL |Rel with Parent |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | | | | | |Type | | |

| | |CONTAINS |CONTAINER |EV (121060, DCM, |1 |M | | |

| | | | |“History”) | | | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx406) Radiology|1-n |M | | |

| | | | |Report Section Content | | | | |

| | | | |National Radiology | | | | |

| | | | |Report Element | | | | |

| | |CONTAINS |CONTAINER |EV (121062, DCM, |1 |M | | |

| | | | |“Request”) | | | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx406) Radiology|1-n |M | | |

| | | | |Report Section | | | | |

| | | | |ContentNational | | | | |

| | | | |Radiology Report | | | | |

| | | | |Element | | | | |

| | |CONTAINS |CONTAINER |EV (121073, DCM, |1 |M | | |

| | | | |“Impression”) | | | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx406) Radiology|1-n |M | | |

| | | | |Report Section | | | | |

| | | | |ContentNational | | | | |

| | | | |Radiology Report | | | | |

| | | | |Element | | | | |

TID xxxx4 Radiology Report Section Content

Contains information for sections used in the context of the TID xxxx1 template

TID xxxx4

RADIOLOGY REPORT SECTION CONTENT

Type: Non-Extensible

| |NL |Rel with |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | |Parent | | | |Type | | |

| | |HAS OBS |INCLUDE |DTID(1001) Observation Context |1 |U | | |

| | |CONTEXT | | | | | | |

| | |CONTAINS |CODE |BCID(7002) Diagnostic Imaging |1-n |U | | |

| | | | |Report Elements | | | | |

| |> |INFERRED FROM|INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

| | |CONTAINS |TEXT |BCID(7002) Diagnostic Imaging |1-n |U | | |

| | | | |Report Elements | | | | |

| |> |INFERRED FROM|INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

| | |CONTAINS |INCLUDE |DTID(2001)Basic Diagnostic |1-n |U | | |

| | | | |Imaging Report Observations | | | | |

No content items other than those defined in Observation Context TID 1001 may be the target of a HAS OBS CONTEXT relationship when TID xx006 is invoked.

TID xxxx508 German Extension

Contains information related to special legislative regulations in Germany.

TID xxxx503

GERMAN EXTENSION

Type: Non-Extensible

| |NL |Rel with Parent |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | | | | | |Type | | |

| |> |CONTAINS |CONTAINER |EV (121066, DCM, “Prior|1 |M | | |

| | | | |Procedure | | | | |

| | | | |Descriptions”) | | | | |

| |>> |CONTAINS |TEXT |EV (121065, DCM, |1 |M | | |

| | | | |“Procedure | | | | |

| | | | |Description”) | | | | |

| |> |CONTAINS |CODE |EV (111532, DCM, |1 |MC |Only for child-bearing |DCID 6096 |

| | | | |“Pregnancy Status”) | | |woman |(Pregnancy Status) |

| |> |CONTAINS |TEXT |EV (121109, DCM, |1 |M | | |

| | | | |“Indications for | | | | |

| | | | |Procedure”) | | | | |

| |> |CONTAINS |PNAME |EV (x1000, DCM, |1 |M | | |

| | | | |“Physician Responsible | | | | |

| | | | |for Indication”) | | | | |

| |> |CONTAINS |PNAME |EV (x1001, DCM, |1 |M | | |

| | | | |”Performing Person”) | | | | |

| |> |CONTAINS |TEXT |EV (x10031001, DCM, |1 |MCM |XOR with Row 7 | |

| | | | |“Radiation Exposure“) | | |IF procedure is subject to | |

| | | | | | | |German X-Ray Regulation | |

| | |CONTAINS |TEXT |EV (x1002, DCM, |1 |MC |XOR with Row 6 | |

| | | | |“Radioactive Substance | | |IF procedure is subject to | |

| | | | |Administered”) | | |German Radiation Control | |

| | | | | | | |Regulation | |

Content Item Descriptions

|Row 67 |By German law only a textural, human readable description of the radiation exposure is required. Detailed |

| |specification of exposure is out of the scope of this context. Such information may be given in a separate |

| |object as described in Supp 94, Radiation Dose Report or Supp 127, CT Radiation Dose Reporting (Dose SR). |

TID xx02 Information concerning the German Radiation Control Regulation

Contains information related to the German Radiation Control Regulation.

TID xx02

INFORMATION CONCERNING THE GERMAN RADIATION CONTROL REGULATION

Type: Non-Extensible

| |NL |Rel with Parent |VT |Concept Name |VM |Req |Condition |Value Set Constraint |

| | | | | | |Type | | |

| |> |CONTAINS |CONTAINER |EV (121066, DCM, “Prior|1 |M | | |

| | | | |Procedure | | | | |

| | | | |Descriptions”) | | | | |

| |>> |CONTAINS |TEXT |EV (121065, DCM, |1 |M | | |

| | | | |“Procedure | | | | |

| | | | |Description”) | | | | |

| |> |CONTAINS |CODE |EV (111532, DCM, |1 |MC |Only for child-bearing |DCID 6096 (Pregnancy Status) |

| | | | |“Pregnancy Status”) | | |woman | |

| |> |CONTAINS |TEXT |EV (121109, DCM, |1 |M | | |

| | | | |“Indications for | | | | |

| | | | |Procedure”) | | | | |

| |> |CONTAINS |PNAME |EV (x1000, DCM, |1 |M | | |

| | | | |“Physician Responsible | | | | |

| | | | |for Indication”) | | | | |

| |> |CONTAINS |PNAME |EV (x1001, DCM, |1 |M | | |

| | | | |”Performing Person”) | | | | |

| |> |CONTAINS |TEXT |EV (x1002, DCM, |1 |M | | |

| | | | |“Radioactive Substance | | | | |

| | | | |Administered”) | | | | |

Item #4: Add the following Definitions to Annex D

DICOM Code Definitions (Coding Scheme Designator “DCM” Coding Scheme Version “01”)

|Code Value |Code Meaning |Definition |

|x994 |German Extension |German extension of the National Radiology Report |

|x1000 |Physician Responsible for Indication |Physician who was responsible for indication |

|x1001 |Performing Person |Person performing the examination |

|x10021001 |Radiation Exposure Radioactive Substance Administered |Estimated radiation dose to the patient resulting from the |

| | |procedure being reported.Radioactive substance administered |

|x10031002 |Radiation ExposureRadioactive Substance Administered |Substance type, amount and route of radioactive substance |

| | |administered. Radiation Exposure |

|x1004 |Performing Person’s Organization Name |Name of the organization the person performing the examination is |

| | |working for |

Item #5: Extend the Context ID 7001

Context ID 7001

Diagnostic Imaging Report Headings

Type: Extensible Version: 20070712

|Coding Scheme Designator |Code Value |Code Meaning |

|(0008,0102) |(0008,0100) |(0008,0104) |

|DCM |121060 |History |

|DCM |121062 |Request |

|DCM |121064 |Current Procedure Descriptions |

|DCM |121066 |Prior Procedure Descriptions |

|DCM |121068 |Previous Findings |

|DCM |121070 |Findings |

|DCM |121072 |Impressions |

|DCM |121074 |Recommendations |

|DCM |121076 |Conclusions |

|DCM |121078 |Addendum |

|DCM |121109 |Indications for Procedure |

|DCM |121110 |Patient Presentation |

|DCM |121113 |Complications |

|DCM |121111 |Summary |

|DCM |121180 |Key Images |

|DCM |X994 |German Extension |

Item #6: Extend the Context ID 7452

Context ID 7452

Item #7: Add a new Annex

Annex X German Translations of Selected Codes used in the DCMR (Normative)

|Coding Scheme |Coding Scheme |Code Value |Code Meaning |Code Meaning |

|Designator |Version | |English Language |German Language |

|LN | |11528-7 |Radiology Report |Radiologischer Befundbericht |

|DCM | |121066 |Prior Procedure Descriptions |Frühere Untersuchungen |

|DCM | |111532 |Pregnancy Status |Schwangerschaft |

|DCM | |121109 |Indications for Procedure |Rechtfertigende Indikation |

|DCM | |123014 |Target Region |Körperregion |

|DCM | |121064 |Current Procedure Descriptions |Untersuchungstechnik |

|DCM | |111060 |Study Date |Datum der Untersuchung |

|DCM | |111061 |Study Time |Zeitpunkt der Untersuchung |

|DCM | |110180 |Study Instance UID |Study Instance UID |

|DCM | |121060 |History |Klinische Angaben |

|DCM | |121062 |Request |Fragestellung |

|DCM | |121071 |Finding |Beschreibung |

|DCM | |121073 |Impression |Wertung |

|DCM | |121075 |Recommendation |Empfehlung |

|DCM | |X990 |Examination |Untersuchung |

|DCM | |X994 |German Extension |Deutsche Erweiterung |

|DCM | |x1000 |Physician Responsible for |Indikationsstellender Arzt |

| | | |Indication | |

|DCM | |x1001 |Performing Person |Durchführende Person |

|DCM | |x1004 |Performing Person’s Organization |Institution in der die Untersuchung |

| | | |Name |durchgeführt wurde |

|DCM | |x10021001 |Radiation Exposure Radioactive |Strahlenexposition Verabreichter radioaktiver|

| | | |Substance Administered |Stoff |

|DCM | |x10031002 |Radiation ExposureRadioactive |Verabreichter radioaktiver Stoff |

| | | |Substance Administered |Strahlenexposition |

-----------------------

Information Concerning....

German Extension

Radiology Report Section Content

Radiology Report Section Content

Medical Content

Examination

National Radiology Report

TID xxxx4

TID xxxx6

TID xxxx5

TID xxxx4

TID xxxx3

TID xxxx2

TID xxxx1

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