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

Page 71​

Name​

 

 

 

Findings​

 

 

 

 

 

Effective Date​

 

 

2015/03/24​

 

 

 

 

 

Version Label​

 

 

DICOM-20150324​

 

 

 

 

Status​

 

 

 

Active​

 

 

 

 

 

Description​

 

 

Recordsclinicallysignificantobservationsconfirmedordiscoveredduringthe​

 

 

 

 

procedure.​

 

 

 

 

 

Classification​

 

 

CDA Section Level​

 

 

 

 

Relationships​

 

 

Included in 7.1 Imaging Report​

 

 

 

Context​

 

 

 

parent node​

 

 

 

 

 

Open/Closed​

 

 

Open​

 

 

 

 

 

Revision History​

 

 

From Consolidated CDA r1.1​

 

 

 

 

 

 

 

DICOM-20150324: Added optional subsections and entries​

 

Business​

Nest​

Element/​

Card​

Elem/Attr​

Data​ Value​

Value​

SubsidiaryTemplate​

Name​

Level​

Attribute​

 

Conf​

Type​

Conf​

 

 

 

Findings​

 

section​

 

 

 

 

 

 

 

 

>​

templateId​

1..1​

SHALL​

II​

 

 

 

 

 

>@​

@root​

1..1​

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UID​

SHALL​2.16.840.1.113883.​

 

 

 

 

 

 

 

10.20.6.1.2​

 

 

 

>​

id​

1..*​

SHALL​

II​

 

 

 

 

 

>​

code​

1..1​

SHALL​

CD​

SHALL​(59776-5, LOINC,​

 

 

 

 

 

 

 

 

"Procedure​

 

 

 

 

 

 

 

 

Findings")​

 

 

Title​

>​

title​

1..1​

SHALL​

ST​

 

 

 

 

Text​

>​

text​

1..1​

COND​

ED​

 

 

9.1.1 Section Text​

 

 

 

 

 

 

 

 

1.2.840.10008.9.19​

 

>​

component​

0..*​

MAY​

 

 

 

 

 

Fetus​

>>​

section​

1..1​

SHALL​

 

 

 

9.8.8 Fetus Findings​

Findings[*]​

 

 

 

 

 

 

 

1.2.840.10008.9.9​

 

>​

component​

0..*​

MAY​

 

 

 

 

 

Subsection[*]​>>​

section​

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9.8.9 Labeled​

 

 

 

 

 

 

 

 

Subsection​

 

 

 

 

 

 

 

 

 

1.2.840.10008.9.10​

 

>​

 

0..1​

MAY​

 

 

 

9.1.2GeneralSection​

 

 

 

 

 

 

 

 

Entries​

 

 

 

 

 

 

 

 

 

1.2.840.10008.9.23​

9.5.1 text​

If entries are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text.​

The narrative text associated with an actionable finding SHOULD be highlighted using styleCode Bold. See Section 9.1.1.1.​

Actionable findings that require a specific follow-up action or procedure SHOULD be referenced from a recommendation in the 9.8.11​ Recommendation section.​

Communication of actionable findings SHOULD be documented in the 9.8.10 Communication of Actionable Findings section.​

- Standard -​

Page 72​

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

Example 9.5.1-1. Findings section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.1.2"/>

<id root="1.2.840.10213.2.62.941494044785528.114289542452452805"/> <code code="59776-5" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Procedure Findings"/> <title>Findings</title>

<text>

<paragraph>

<caption>Finding</caption>

<content ID="Fndng2">The cardiomediastinum is... </content> </paragraph>

<paragraph>

<caption>Diameter</caption> <content ID="Diam2">45mm</content>

</paragraph>

...

</text>

<entry>

<templateId root="2.16.840.1.113883.10.20.6.2.12"/>

...

</entry>

<!-- see examples for other sections/entries --> </section>

9.6 Impression​

Template ID​

 

1.2.840.10008.9.5​

 

 

 

Name​

 

Impression​

 

 

 

Effective Date​

 

2015/03/24​

 

 

 

Version Label​

 

DICOM-20150324​

 

 

 

Status​

 

Active​

 

 

 

 

Description​

 

The most important diagnoses or other clinical conclusions that can be made from​

 

 

the imaging observations and other clinical information are recorded here. This​

 

 

section may include recommendations for additional imaging tests or other actions,​

 

 

as well as global assessments, such as BI-RADS Categories or the equivalent.​

Classification​

 

CDA Section Level​

 

 

 

Relationships​

 

Included in 7.1 Imaging Report​

 

 

Context​

 

parent node​

 

 

 

Open/Closed​

 

Open​

 

 

 

 

Revision History​

 

DICOM-20150324: Initial version​

 

 

Business Name​ Nest​

Element/​

Card​

Elem/Attr​

Data​ Value​

Value​

SubsidiaryTemplate​

Level​

Attribute​

 

Conf​

Type​ Conf​

 

 

Impression​

section​

1..1​

SHALL​

 

 

 

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>​

id​

1..*​

SHALL​

II​

 

 

- Standard -​

 

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

Page 73​

Business Name​ Nest​

Element/​

Card​

Elem/Attr​

Data​ Value​

Value​

SubsidiaryTemplate​

 

Level​

Attribute​

 

Conf​

Type​ Conf​

 

 

 

 

>​

code​

1..1​

SHALL​

CD​ SHALL​(19005-8, LOINC,​

 

 

 

 

 

 

"Impressions")​

 

 

Title​

>​

title​

1..1​

SHALL​

ST​

 

 

 

Text​

>​

text​

1..1​

COND​

ED​

 

9.1.1 Section Text​

 

 

 

 

 

 

 

1.2.840.10008.9.19​

 

>​

component​

0..1​

MAY​

 

 

 

 

CommunicationOf​>>​

section​

1..1​

SHALL​

 

 

9.8.10​

 

Actionable​

 

 

 

 

 

 

Communication of​

Findings​

 

 

 

 

 

 

Actionable Findings​

 

 

 

 

 

 

 

1.2.840.10008.9.11​

 

>​

component​

0..1​

MAY​

 

 

 

 

KeyImages​

>>​

section​

1..1​

SHALL​

 

 

9.8.6 Key Images​

 

 

 

 

 

 

 

1.3.6.1.4.1.19376.​

 

 

 

 

 

 

 

1.4.1.2.14​

 

 

>​

component​

0..*​

MAY​

 

 

 

 

Recommendation​>>​

section​

1..1​

SHALL​

 

 

9.8.11​

 

 

 

 

 

 

 

 

Recommendation​

 

 

 

 

 

 

 

1.2.840.10008.9.12​

 

>​

entry​

0..*​

MAY​

 

 

 

 

Coded​

>>​

observation​

1..1​

SHALL​

CD​

 

10.1 Coded​

Observation​

 

 

 

 

 

 

Observation​

 

 

 

 

 

 

 

2.16.840.1.113883.​

 

 

 

 

 

 

 

10.20.6.2.13​

Example 9.6-1. Impression section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.2.27"/>

<id root="1.2.840.10213.2.62.994948294044785528.11422458954285205"/> <code code="19005-8"

codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC"

displayName="Impressions"/>

<title>Impression</title>

<text>This exam identified ...</text> <!-- other sections and entries here -->

</section>

9.7 Addendum​

Template ID​

1.2.840.10008.9.6​

Name​

Addendum​

Effective Date​

2015/03/24​

Version Label​

DICOM-20150324​

Status​

Active​

Description​

Addendum section for imaging report includes supplemental information​

 

added to the original document contents..​

- Standard -​

Page 74​

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

 

Classification​

 

 

CDA Section Level​

 

 

 

Relationships​

 

 

Included in 7.1 Imaging Report​

 

 

Context​

 

 

 

parent node​

 

 

 

 

Open/Closed​

 

 

 

Open​

 

 

 

 

Revision History​

 

 

DICOM-20150324: Initial version​

 

 

Business​

Nest​

Element/​

Card​

Elem/AttrConf​Data​ Value​

Value​

Subsidiary​

Name​

Level​

Attribute​

 

 

Type​ Conf​

 

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Addendum[*]​

 

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id​

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title​

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Text​

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text​

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9.1.1 Section Text​

 

 

 

 

 

 

 

 

1.2.840.10008.9.19​

 

>​

author​

1..1​

SHALL​

 

 

 

 

Time​

>>​

time​

1..1​

SHALL​

TS​

 

 

 

 

>>​

assignedAuthor​1..1​

SHALL​

 

 

 

 

AuthorID​

>>>​

id​

1..*​

SHALL​

II​

 

 

 

 

>>>>​

assignedPerson​1..1​

SHALL​

 

 

 

 

AuthorName​

>>>>>​

name​

1..1​

SHALL​

PN​

 

 

 

 

>​

component​

0..1​

MAY​

 

 

 

 

Communication​>>​

section​

1..1​

SHALL​

 

 

 

9.8.10​

OfActionable​

 

 

 

 

 

 

 

Communication of​

Findings​

 

 

 

 

 

 

 

ActionableFindings​

 

 

 

 

 

 

 

 

1.2.840.10008.9.11​

 

>​

 

0..1​

MAY​

 

 

 

9.1.2 General​

 

 

 

 

 

 

 

 

Section Entries​

 

 

 

 

 

 

 

 

1.2.840.10008.9.23​

9.7.1 author​

NotethattheAuthoridentifiedinthedocumentheaderistheauthoroftheoriginalreport,asthatparticipationsetsthedefaultauthoring​ context for the report. The Author participation in this section shall be present, and identifies the author of the addendum, even if the​ same as the author of the original report.​

9.7.2 component/section - Communication of Actionable Findings​

It is possible for an imaging report to be legally signed (authenticated) prior to the Actionable Findings being properly communicated.​ In this event, an addendum to the imaging report is often created to document the communication of the actionable findings. This can​ be included in the section/text of the 9.7 Addendum, or using the 9.8.10 Communication of Actionable Findings subsection.​

Example 9.7.2-1. Addendum section example​

<section classCode="DOCSECT" moodCode="EVN" ID="Adndm"> <templateId root="1.2.840.10008.9.6"/>

<id root="1.2.840.10213.2.62.7906994044785528.1142895428068506"/>

- Standard -​

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

Page 75​

<code code="55107-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName=" Addendum"/>

<title>Addendum</title>

<text>The supplemental information added to the original document...</text> <author>

<time value="20140605143000+0500"/> <assignedAuthor>

<id extension="23454345" root="2.16.840.1.113883.19.5"/> <assignedPerson>

<name><given>Henry</given> <family>Radiologist</family></name> </assignedPerson>

</assignedAuthor>

</author>

</section>

9.8 Sub-sections​

9.8.1 Request​

Template ID​

1.2.840.10008.9.7​

Name​

Request​

Effective Date​

2015/03/24​

Version Label​

DICOM-20150324​

Status​

Active​

Description​

Information about the requested imaging studies and associated tests. It may​

 

include information on the reason for the request, and on any validation of the​

 

request by clinical decision support against relevant appropriateness criteria.​

Classification​

CDA Section Level​

Relationships​

Included in 9.2 Clinical Information​

Context​

parent node​

Open/Closed​

Open​

Revision History​

DICOM-20150324: Initial version​

Business​

Nest​

Element/​

Card​

Elem/AttrConf​Data Type​Value​

Value​

Subsidiary​

Name​

Level​

Attribute​

 

 

 

Conf​

 

Template​

Request​

 

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1..1​

SHALL​

 

 

 

 

 

>​

templateId​

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id​

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>​

code​

1..1​

SHALL​

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SHALL​(55115-0, LOINC,​

 

 

 

 

 

 

 

"Request")​

 

Title​

>​

title​

1..1​

SHALL​

ST​

 

 

 

Text​

>​

text​

1..1​

COND​

ED​

 

 

9.1.1 Section Text​

 

 

 

 

 

 

 

 

1.2.840.10008.9.19​

CDSRecord​>>​

content​

0..*​

MAY​

ST​

 

 

 

Text[*]​

 

 

 

 

 

 

 

 

*​

>>@​

@ID​

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XML ID​

 

 

 

- Standard -​

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