Supplement 127: CT Radiation Dose Reporting (Dose SR)



Digital Imaging and Communications in Medicine (DICOM)

Supplement 150: 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: Draft Public Comment 08

November 26, 2009

Table of Contents

Document History 3

Open Issues and Work To Do 4

Foreword 4

Scope and Field of Application 4

Changes to NEMA Standards Publication PS 3.16-2007 6

Item #1: Add new Section to Annex A 7

NATIONAL RADIOLOGY REPORT TEMPLATES 7

TID xxxx1 National Radiology Report 7

TID xxxx2 Examination 8

TID xxxx3 Medical Content 9

TID xxxx4 Radiology Report Section Content 10

TID xxxx5 National Extensions 10

TID xxxx6 German Extension 11

TID xxxx7 Information concerning the German X-Ray and Radiation Control Regulation 11

Item #2: Add the following Definitions to Annex D 12

Item #3: Extend the Context ID 7001 12

Item #4: Add a new Annex 13

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 template 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 |

|08 |November, 2009 |- Changed report structure to allow for a variety of national extensions (description on |

| | |scope and field has been adapted). Conditions for radiation exposure and radioactive |

| | |substance administered have been modified to address hybrid imaging (e.g. PET/CT) where |

| | |reporting of dose and activity of radioactive substances administered are required. |

| | |- Clarification on person observer mandatory attributes has been added. |

| | |- Changed TID xxxx1 “NATIONAL RADIOLOGY REPORT” type to non-extensible, TID xxxx2 |

| | |“EXAMINATION” and TID xxxx3 “MEDICAL CONTENT” types to extensible. |

| | |- Clarification has been added that order of sections is not significant in TID xxxx3 |

| | |“MEDICAL CONTENT”. |

| | |- Description of contents of TID xxxx3 “MEDICAL CONTENT” has been added. |

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. | |

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

The National Radiology Report DICOM SR templates are based on the report structure and contents of PS 3.16 TID 2000 “Basic Diagnostic Imaging Report”.

Additional information is contained in sections that extend the basid TID 2000 structure and contents:

- The Examination section includes basic information on the current imaging procedure.

- The Medical Content section comprises relevant medical history data, information on the current request (i.e. clinical question that is expected to be answered by the requested procedure) and impressions on the current imaging procedure that has been performed.

- National Extensions allow for country-specific extensions that cover national documentation requirements such as summaries on the applied dose for imaging procedures using ionizing radiation.

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.

German Extension

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 #012: 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.

TID xxxx1

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 those person observers, | |

| | | | | | | |requirement types as specified | |

| | | | | | | |in TID 1003 apply. That means | |

| | | | | | | |that “Person Observer Name” is | |

| | | | | | | |the only mandatory | |

| | | | | | | |attribute.the respective roles | |

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

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

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

| |> |CONTAINS |INCLUDE |DTID(xxxx2) Examination |1 |M | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx3) Medical Content |1 |M | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx5) NationalGerman |1 |MC |Required if specificfor | |

| | | | |Extensions | | |« nationalGerman Radiology | |

| | | | | | | |Reportrequirements » for the | |

| | | | | | | |documentation of procedures | |

| | | | | | | |using ionizing radiation exist | |

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

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

| |>> |CONTAINS |INCLUDE |DTID(xxxx4) Radiology Report |1 |U | | |

| | | | |Section Content | | | | |

No content items other than those defined in Observation Context TID 1001 may be the target of a HAS OBS CONTEXT relationship when TID xxxx1 is invoked.

TID xxxx2 Examination

Contains information related to the examination.

TID xxxx2

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 (123014, DCM, |1 |MC |XOR with Row 4 | |

| | | | |“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 8 |Concept Name is the Root Concept Name (title) of the Radiation Dose Structured Report composite object |

| |instance. |

TID xxxx3 Medical Content

Contains the medical content of the report that comprises relevant medical history data, information on the current request (i.e. clinical question that is expected to be answered by the requested procedure) and impressions on the current imaging procedure that has been performed.

TID xxxx3

MEDICAL CONTENT

Type: Non-Extensible Order : Non-Significant

| |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(xxxx4) Radiology |1 |M | | |

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

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

| | | | |“Request”) | | | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx4) Radiology |1 |M | | |

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

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

| | | | |“Impression”) | | | | |

| |> |CONTAINS |INCLUDE |DTID(xxxx4) Radiology |1 |M | | |

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

TID xxxx4 Radiology Report Section Content

SContains information for section structure and contents used in the context of the 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 xxxx4xx006 is invoked.

TID xxxx5 National Extensions

Country-specific extensions that cover national documentation requirements.

TID xxxx5

NATIONAL EXTENSIONS

Type: 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 |TEXT |EV (x1001, DCM, |1 |MC |Required for procedures | |

| | | | |“Radiation Exposure“) | | |that are subject to the | |

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

| | |CONTAINS |TEXT |EV (x1002, DCM, |1 |MC |Required for procedures | |

| | | | |“Radioactive Substance | | |that are subject to the | |

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

| | | | | | | |Regulation | |

Content Item Descriptions

|Row 6 |By German law only a textual, 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). |

Item #24: 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 |Radiation Exposure |Estimated radiation dose to the patient resulting from the |

| | |procedure being reported. |

|x1002 |Radioactive Substance Administered |Substance type, amount and route of radioactive substance |

| | |administered. |

Item #35: 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 #47: 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 | |X994 |German Extension |Deutsche Erweiterung |

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

| | | |Indication | |

|DCM | |x1001 |Radiation Exposure |Strahlenexposition |

|DCM | |x1002 |Radioactive Substance Administered |Verabreichter radioaktiver Stoff |

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

National Extensions

TID xxxx7

TID xxxx5

Information Concerning The German X-Ray and Radiation Control Regulation

German Extension

Radiology Report Section Content

Radiology Report Section Content

Medical Content

Examination

National Radiology Report

TID xxxx4

TID xxxx6

[pic]

TID xxxx4

TID xxxx3

TID xxxx2

TID xxxx1

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