Материал: part20
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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Description |
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DICOM Object Catalog lists all referenced objects and their parent Series and |
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Studies,plusotherDICOMattributesrequiredforretrievingtheobjects.TheDICOM |
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Object Catalog section is not intended for viewing and may contain empty section |
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text. |
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Classification |
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CDA Section Level |
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Relationships |
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Included in 9.3 Imaging Procedure Description |
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Context |
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parent node |
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Open/Closed |
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Open |
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Revision History |
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From Consolidated CDA r1.1 |
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Business |
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Elem/AttrConf Data |
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DICOMCatalog |
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templateId |
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>@ |
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UID |
SHALL2.16.840.1.113883. |
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10.20.6.1.1 |
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id |
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code |
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SHALL(121181, DCM, |
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"Dicom Object |
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Catalog") |
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9.1.1 Section Text |
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1.2.840.10008.9.19 |
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SHOULD |
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Study[*] |
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10.6 Study Act |
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2.16.840.1.113883. |
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10.20.6.2.6 |
Example 9.8.7-1. DICOM object catalog section example
<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.1.1"/> <id root="1.2.840.10213.2.62.70447834679.11429737"/> <code code="121181" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="DICOM Object Catalog"/> <entry>
<!-- **** Study Act **** -->
<act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.6"/>
<id root="1.2.840.113619.2.62.994044785528.114289542805"/> <code code="113014" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Study"/>
<!-- **** Series Act ****--> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">
<id root="1.2.840.113619.2.62.994044785528.20060823223142485051"/> <code code="113015" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Series">
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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</code> |
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<!-- **** SOP Instance UID *** --> |
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<!-- 2 References --> |
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<entryRelationship typeCode="COMP"> |
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<observation classCode="DGIMG" moodCode="EVN"> |
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<templateId root="2.16.840.1.113883.10.20.6.2.8"/> |
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... |
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</observation> |
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</entryRelationship> |
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<entryRelationship typeCode="COMP"> |
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<observation classCode="DGIMG" moodCode="EVN"> |
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<templateId root="2.16.840.1.113883.10.20.6.2.8"/> |
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... |
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</observation> |
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</entryRelationship> |
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</act> |
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</entryRelationship> |
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</act> |
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</entry> |
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9.8.8 Fetus Findings |
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Template ID |
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1.2.840.10008.9.9 |
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Name |
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Fetus Findings |
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Effective Date |
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2015/03/24 |
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Version Label |
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DICOM-20150324 |
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Status |
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Active |
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Description |
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Records observations related to a fetus confirmed or discovered during |
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an imaging procedure. |
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Classification |
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CDA Section Level |
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Relationships |
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Included in 9.5 Findings |
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Context |
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parent node |
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Open/Closed |
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Open |
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Revision History |
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DICOM-20150324: Initial version |
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Business |
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Element/ |
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Elem/Attr Conf Data |
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Name |
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Conf |
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Template |
Fetus |
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section |
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Findings[*] |
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templateId |
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>@ |
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SHALL1.2.840.10008.9.9 |
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id |
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code |
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SHALL(76514-9, LOINC, |
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"Fetal Study |
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observation") |
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title |
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Text |
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text |
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9.1.1 Section Text |
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1.2.840.10008.9.19 |
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subject |
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- Standard -
Page 88 |
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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>> |
relatedSubject1..1 |
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>>> |
code |
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SHALL |
CE SHALL(121026, DCM, |
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"Fetus") |
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subject |
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FetusID |
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name |
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component |
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Subsection[*]>> |
section |
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9.8.9 Labeled |
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Subsection |
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1.2.840.10008.9.10 |
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9.1.2 General |
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Section Entries |
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1.2.840.10008.9.23 |
For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget/PatientRole/Patient in the CDA header.Informationonthefetusismappedtosubject/relatedSubject/SubjectPersonattheCDAsectionlevel.Bothcontextinformation on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.
9.8.8.1 name - FetusID
The subject/relatedSubject/subject/name element is used to store the fetus ID, typically a pseudonym such as "fetus A". This shall be present even if only one fetus is identified in the document.
Example 9.8.8-1. Fetus Findings section example
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.27" /> <id root="1.2.840.10213.2.62.70447834679.11429737"/> <code code="76514-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Fetal Study observation" /> <title>Fetus #1</title>
<text>Estimated gestational age of 27 weeks... </text> <relatedSubject>
<code code="121026" codeSystem="1.2.840.10008.2.16.4" displayName="Fetus"/> <subject>
<name>Fetus 1</name> </subject>
</relatedSubject>
</section>
9.8.9 Labeled Subsection
Template ID |
1.2.840.10008.9.10 |
Name |
Labeled Subsection |
Effective Date |
2015/03/24 |
Version Label |
DICOM-20150324 |
Status |
Active |
Description |
Narrative or coded subsection that allows organization of content for a labeled |
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topic (a particular organ or anatomic feature, a lesion, a tumor, etc.). The |
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section.code shall be absent, but the section.title shall be present. |
Classification |
CDA Section Level |
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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Relationships |
Included in 9.5 Findings |
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Context |
parent node |
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Open/Closed |
Open |
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Revision History |
DICOM-20150324: Initial version |
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Business |
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Elem/Attr Conf Data Value |
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Subsection[*] |
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templateId |
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>@ |
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SHALL1.2.840.10008.9.10 |
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id |
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> |
code |
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SHALL NOT |
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Title |
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title |
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[See 9.8.9.1 title] |
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noNull |
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Text |
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9.1.1 Section Text |
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1.2.840.10008.9.19 |
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MAY |
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Subsection[*]>> |
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9.8.9 Labeled |
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Subsection |
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1.2.840.10008.9.10 |
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9.1.2 General |
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Section Entries |
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1.2.840.10008.9.23 |
9.8.9.1 title
The title element is used to identify the topic (specific organ or anatomic feature, abnormality, lesion, etc.) as the subject of the sub- sectionfindingsinthehumanreadabledocument.Asthereisnosection.code,thisistherequiredmechanismtorepresentthesection purpose as free text.
9.8.9.2 component/section Labeled Subsection
This template invokes itself recursively to allow arbitrarily deep nested subsections.
Example 9.8.9.2-1. Labeled sub-section example
<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.10" />
<id root="1.2.840.10213.2.62.7044794679.114296787"/> <title>Liver</title>
<text>No evidence of cirrhosis, nodular regeneration, or ... </text> </section>
9.8.10 Communication of Actionable Findings
Template ID |
1.2.840.10008.9.11 |
Name |
Communication of Actionable Findings |
Effective Date |
2015/03/24 |
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DICOM-20150324 |
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Description |
A section that documents the notification of an actionable finding to a provider or other |
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person responsible for patient care. The documentation in narrative text, and optionally in |
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a coded entry, includes by whom, to whom, and at what date/time. |
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Specificfindings,includingactionable(aka.critical)findingsdocumentedintextorascoded |
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entries, are typically found in the 9.5 Findings. The actionable findings may be duplicated |
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in the 9.6 Impression in either text or as coded entries. The actionable findings may be new |
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(critical) or a change to a previous report/diagnosis (discrepant). |
Classification |
CDA Section and Entry Level |
Relationships |
Included in 9.6 Impression and 9.7 Addendum |
Context |
parent node |
Open/Closed |
Open |
Revision History |
DICOM-20150324: Initial version |
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Actionable |
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Findings |
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SHALL1.2.840.10008.9.11 |
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id |
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code |
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SHALL(73568-8, LOINC, |
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"Communication of |
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Critical Results") |
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Content[*] |
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[See 9.8.10.1 |
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section/text/content |
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- narrative] |
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@ID |
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FindingRef |
>>> |
linkHtml |
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FindingURI |
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@href |
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URL(XML |
#findingRef |
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IDREF) |
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> |
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Communication[*]>> |
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@classCode |
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SHALLACT |
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@moodCode |
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SHALLEVN |
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>>@ |
@ID |
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SHALL |
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>>> |
code |
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SHALL |
CD |
SHALL(121291, DCM, |
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"Results |
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communicated") |
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CommTime |
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effectiveTime |
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>>> |
text |
1..1 |
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Ref |
>>>> |
reference |
1..1 |
SHALL |
URL(XML |
# contentRef |
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IDREF) |
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>>> |
performer |
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