Материал: part20

Example 8.2.4.2-2. 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>

Example 8.2.4.2-3. dataEnterer example​

<dataEnterer>

<assignedEntity typeCode="ENT">

<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>

8.3 Parent Document​

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8.3.1 relatedDocument​

A document may have two types of parent document:​

•​Asupersededversionthatthepresentdocumentwhollyreplaces(typeCode=RPLC).Documentsmaygothroughstagesofrevision​ prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other prelim-​ inary 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 trans-​ formation from a DICOM Structured Report (SR) document (see Annex C).​

TheCDAdocumentmanagementvocabularyincludesatypeCodeAPND(append)relationshiptoaparentdocument.Thisrelationship​ type is not supported in this specification; rather, append is effected by creating a replacement document with an 9.7 Addendum.​

8.3.2 parentDocument/setId and versionNumber​

COND: If and only if the setID element is present, the versionNumber element SHALL be present.​

Example 8.3.2-1. 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>

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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture​ Page 59​

9 Section-level Templates​

9.1 General Requirements For Sections​

9.1.1 Section Text​

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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.​

AsnotedintheCDAR2specification,thedocumentoriginatorisresponsibleforensuringthatthenarrativeblockcontainsthecomplete,​ human readable, attested content of the section. Structured entries support computer processing and computation, and are not a re-​ placement 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 in any order and at any point within the narrative block text as allowed by the CDA R2 specification.​

9.1.1.1 <content> Markup and Links From Entries​

The 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 nar-​ rative 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 9.5 Findings and/or 9.6 Impression sections.​

9.1.1.2 <linkHtml> Markup and Internal References​

The 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 9.6 Impression section to the specific, detailed​ measurement evidencing a problem that was identified in the text of the 9.5 Findings section.​

9.1.1.3 <renderMultiMedia> Markup and Graphical Content​

The 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 SHALL link to an observationMedia structured​ entry using the XML ID of that entry (see CDA R2 Specification, section 4.3.5.6).​

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