Материал: part20

Note 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.​

Also,theIDofthistemplateisnotrepresentedinatemplateIDelement.Rather,thetemplateIDoftheinvokingtemplateimplicitlyincludes​ the elements specified by this template.​

9.1.2.1 templateId​

This templateId may be used to identify the template(s) used to generate/constrain the content of the section. This is in addition to​ the templateId of the section level template, and typically represents clinical sub-specialty requirements. See Section 5.1.1 on the​ structure and use of the templateId.​

9.1.2.2 author​

Theauthorparticipationallowstherecordingofanauthorforasection,equivalenttotheTID1002“ObserverContext”.Eitheraperson​ or a device may be identified as the author for a section or subsection.​

COND: Either the assignedPerson or assignedAuthoringDevice element SHALL be present.​

Example 9.1.2.2-1. 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>

9.1.2.3 section/entry​

A section may contain CDA entries that represent clinical statements in coded form (using the 10.1 Coded Observation template),​ numeric measurements (using the 10.5 Quantity Measurement template), images to be displayed in the narrative block (using the​ 10.3observationMediatemplate,andinvokedfromarenderMultiMediaelement),orreferencestoexternalimagesorannotatedimages​ (using the 10.8 SOP Instance Observation template).​

These entries may appear in any order.​

9.1.2.4 regionOfInterest​

Section templates defined in this Implementation guide 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​ 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, including the full range of 2D and 3D​ presentations defined in DICOM.​

- Standard -​

DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture​ Page 67​

9.2 Clinical Information​

- Standard -​

Example 9.2-1. Clinical Information section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.2"/>

<id root="1.2.840.10213.2.62.994044785528.114289542805"/> <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 referred for evaluation of suspected pulmonary embolism.</text> <!---see examples for other sections/entries -->

</section>

9.3 Imaging Procedure Description​

- Standard -​

Example 9.3-1. Current Imaging Procedure description section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.3"/>

<id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/> <code code="55111-9" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Current Imaging Procedure Description"/> <title>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 Procedure Technique template example - required here -->

<!-- See DICOM Imaging Catalog template example - required here --> <!---see examples for other sections/entries -->

</section>

9.3.1 component/section Radiation Exposure and Protection Information​

COND: If the documented service utilizes ionizing radiation, a 9.8.5 Radiation Exposure and Protection Information section MAY be​ present.​

9.4 Comparison Study​

- Standard -​

Example 9.4-1. Comparison study section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.4"/>

<id root="1.2.840.10213.2.62.994056444785528.1142893564536542805"/> <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> <! ---see examples for other sections/entries />

</section>

9.5 Findings​

- Standard -​