Материал: part03

Note​

If a document contains an Identical Documents Sequence then it will not be further duplicated without producing a new​ complete set of duplicate SOP Instances with re-generated Identical Documents Sequences. This is a consequence of the​ rules for modification of document content in PS3.4. For example, if there are two identical reports and an application is​ creatingathirdidenticalreport,thenthefirsttworeportsmustbere-generatedinorderthattheirIdenticalDocumentsSequence​ will reference the new duplicate document and all other identical documents.​

If a new document is created using content from a document that contains an Identical Documents Sequence and is part of the same​ Requested Procedure, then the new document shall only contain a new Identical Documents Sequence if the new document is du-​ plicated. The Predecessor Documents Sequence in all the new documents shall contain references to the original document and all​ its duplicates as well as any other documents from which content is included.​

Note​

It is up to an implementation to decide whether a new document is duplicated across multiple Studies. This may require user​ input to make the decision.​

C.17.2.3CurrentRequestedProcedureEvidenceSequenceandPertinentOtherEvidence​

Sequence​

The intent of the Current Requested Procedure Evidence Sequence (0040,A375) is to reference all evidence created in order to sat-​ isfy the current Requested Procedure(s) for this SR Document. This shall include, but is not limited to, all current evidence referenced​ in the content tree.​

For a completed SR Document satisfying (i.e., being the final report for) the current Requested Procedure(s), this Sequence shall list​ the full set of Composite SOP Instances created for the current Requested Procedure(s). For other SOP Instances that include the​ SR Document General Module, this Sequence shall contain at minimum the set of Composite SOP Instances from the current Re-​ quested Procedure(s) that are referenced in the content tree.​

The Pertinent Other Evidence Sequence (0040,A385) Attribute is used to reference all other evidence considered pertinent for this​ SR Document that is not listed in the Current Requested Procedure Evidence Sequence (0040,A375).​

This requires that the same SOP Instance shall not be referenced in both of these Sequences.​

ForthepurposesofinclusionintheCurrentRequestedProcedureEvidenceSequence(0040,A375)andthePertinentOtherEvidence​ Sequence (0040,A385), the set of Composite SOP Instances is defined to include not only the images and waveforms referenced in​ thecontenttree,butalsoallpresentationstates,realworldvaluemapsandotheraccompanyingCompositeInstancesthatarereferenced​ from the Content Items.​

C.17.2.4 Identified Person or Device Macro​

Table C.17-3b defines the Attributes that identify a person or a device. This Macro contains content equivalent to TID 1002 (see​ PS3.16).​

Table C.17-3b. Identified Person or Device Macro Attributes​

- Standard -​

Note​

ThismightbeobtainedfromacorrespondingHL7v2​ message containing PV1:10 Hospital Service.​

Only a single Item is permitted in this Sequence.​

- Standard -​

C.17.2.5 Verifying Observer, Author Observer and Participant Sequences​

The Verifying Observer Sequence (0040,A073), Author Observer Sequence (0040,A078), and Participant Sequence (0040,A07A)​ identify significant contributors to the SR document. The Author creates the clinical content of the document. The Verifying Observer​ verifies and accepts legal responsibility for the content. Other participants may include an Attestor, a person identified as a Participant​ who"signs"anSRdocument,butwhodoesnothavelegalauthoritytoverifytheclinicalcontent.E.g.,anSRdocumentmaybeauthored​ and attested by a resident, and then verified by a staff physician; or a document may be authored by a CAD device and attested by​ a technologist, and then verified by a physician; or a technologist working with a measurement software package may be the author,​ the package is a Source participant, and the final content is verified by a physician.​

AnindividualshallnotbeidentifiedinboththeVerifyingObserverSequence(asthelegalauthenticator)andintheParticipantSequence​ as an Attestor. An individual may be identified in both the Author Observer Sequence and either the Verifying Observer Sequence or​ the Participant Sequence.​

TheparticipationDateTimefor theVerifyingObserverisconveyedinVerificationDateTime(0040,A030)withintheVerifyingObserver​ Sequence, for the Author Observer in Observation DateTime (0040,A032) in the top level Data Set (see Section C.17.3), and for​ other participants in Participation DateTime (0040,A082) within the Participant Sequence.​

C.17.2.6 Equivalent CDA Document​

The Referenced Instance Sequence (0008,114A) with a Purpose of Reference Code Sequence value of (121331, DCM, "Equivalent​ CDA Document") identifies an HL7 Clinical Document Architecture (CDA) Document that contains clinical content equivalent to this​ SR Document SOP Instance. This referenced CDA Document may be a source document that was transformed to create this SR​ Document, or it may be a transcoding of the content created simultaneously for both the SR Document and the CDA Document.​

Note​

1.​Reference to a CDA Document created as a transcoding of the SR Document subsequent to the creation of the SR​ SOP Instance would not be encodable in that SOP Instance.​

2.​ThereisnorequirementthatthetransformortranscodingbetweenDICOMSRandHL7CDAbereversible.Inparticular,​ someAttributesoftheDICOMPatient,Study,andSeriesIEshavenocorrespondingstandardencoding intheHL7CDA​ Header, and vice versa. Such Attributes, if transcoded, may need to be encoded in implementation-dependent "local​ markup" (in HL7 CDA) or Private Data Elements (in DICOM SR) in an implementation-dependent manner; some such​ Attributessmaynotbetranscodedatall.Itisaresponsibilityofthetransformingapplicationtoensureclinicalequivalence.​

3.​Due to the inherent differences between DICOM SR and HL7 CDA, a transcoded document should have a different UID​ than the source document.​

The Referenced SOP Instance UID (0008,1155) in Items of this Sequence is mapped to the native HL7 Instance Identifier through​ the HL7 Structured Document Reference Sequence (0040,A390) of the SOP Common Module.​

C.17.2.7 Completion Flag​

Completion Flag (0040,A491) describes the estimated degree of completeness of this SR Document.​

Completeness of an SR Document is defined in relation to the scope of the Requested Procedure and the scope of the Root Concept​ Name. E.g., a Completion Flag value of "COMPLETE" may indicate that the document content includes all significant observations​ within the topic of the root Concept Name (as restricted by any Concept Modifiers) that are related to the Requested Procedure​ identified in the Referenced Request Sequence (0040,A370).​

The criteria by which the Application Entity determines completeness shall be specified in the Conformance Statement.​

Note​

1.​The concept of "completeness" is independent of the concept of preliminary or final; see the description of Preliminary​ Flag (0040,A496). An SR Document may be Complete, but may also be Preliminary pending a laboratory test result.​

- Standard -​

2.​A Requested Procedure may have multiple Complete SR Documents on different topics. These SR Documents may​ use the same or different SOP Classes.​

3.​For example, an AE might state in its Conformance Statement that it allows an authorized user to check a box on the​ userinterfacetoindicatethatanSRDocumentisComplete.Asanotherexample,anAEmightstatethatanSRDocument​ created from a fully filled in user interface screen will be marked as Complete. As another example, an AE might state​ that only Verified SR Documents will be marked as Complete.​

C.17.3 SR Document Content Module​

This section specifies the Attributes contained in the SR Document Content Module. The Attributes in this Module convey the content​

of an SR Document.​

Table C.17-4. SR Document Content Module Attributes​

Table C.17-5. Document Content Macro Attributes​

- Standard -​

- Standard -​