Материал: part20

9.8.10.1 section/text/content - narrative​

Each documented act of communication of actionable findings SHALL be included as narrative in a section/text/content element,​ labeled with an XML ID (see Section 9.1.1.1).​

Note​

The following text content for such a block is specified in the RSNA Radiology Reporting Templates, Template 297: Commu-​ nication of Actionable Finding (http://radreport.org/txt-mrrt/0000297):​

method [discussed directly | discussed by telephone | described in message]​

by [person]​

to [person]​

on [<date>] at [<time>]​

The documentation may also provide a linkHtml reference to the actionable finding narrative elsewhere in the report, e.g., in the 9.5​ Findings or 9.8.4 Complications section (see Section 9.1.1.2).​

9.8.10.2 entry/act​

AstructuredentryrepresentationoftheactofcommunicationMAYbeincludedinthesection.Thisentrydoesnotnecessarilyrepresent​ the entirety of the act as described in the narrative text, e.g., the communication method and actual content of the communication is​ not represented, nor whether the receiver acknowledged the communication ("read-back"). The act/text/reference element SHALL​ include an XML IDREF value pointing to the associated narrative content block.​

9.8.10.3 entry/act/effectiveTime​

The entry/act/effectiveTime element represents the date and time that actionable findings were communicated. The time that the​ findingswerefirstobservedisrecordedintheeffectiveTimeelementoftheoriginalobservation,aslinkedthroughthesection/text/con-​ tent/linkHtml element.​

9.8.10.4 entry/act/participant​

The entry/act/participant element represents the notified party (@typecode = "NOT"). This could be the patient.​

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Example 9.8.10-1. Communication of Actionable Results section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.11"/>

<id root="1.2.840.10213.2.62.7044794679.114296787"/> <code code="73568-8"

codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Communication of Critical Results"/>

<title>Communication of Actionable Results</title> <text>

<content ID=CR1>Dr. Smith was phoned at 262-966-0120 at 3:14pm on Wednesday, June 4, 2014, and the 4mm lung nodule was discussed directly with Dr. Smith to explain the follow-up recommendation of ...</content>

</text>

<entry>

<act classCode="ACT" moodCode="EVN"> <code code="121291"

codeSystem="1.2.840.10008.2.16.4"

codeSystemName="DCM" displayName="Results Communicated"/>

<text>

<reference value="#CR1"/> </text>

<effectiveTime value="20140604221400-0700"/> <performer>

<assignedEntity>

<id root="1.2.840.10213.2.62.7044794679.114298686"/> <assignedPerson>

<name>Jane Doctor</name> </assignedPerson>

</assignedEntity>

</performer>

<participant typeCode="NOT"> <participantRole>

<telecom value="tel:262-966-0120"/> <playingEntity>

<name>Dr. Smith</name> </playingEntity>

</participantRole>

</participant>

</act>

</entry>

</section>

9.8.11 Recommendation​

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9.8.11.1 text/content​

EachdocumentedrecommendationSHALLbeincludedasnarrativeinacontentelement,labeledwithanXMLID(seeSection9.1.1.1​ <content> Markup and Links From Entries). The content element NEED NOT be top level markup within the section/text element; it​ MAY be wrapped in another allowed narrative block markup, such as paragraph, list/item, or table/row/cell.​

If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element.​

Each recommendation SHOULD have a corresponding structured entry.​

9.8.11.2 entry/procedure​

The Recommendation section SHOULD include entries for recommended follow-up actions or procedures.​

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Note​

While this entry may be a trigger for a tracking system for ensuring follow up on recommendations, the imaging study report​ only conveys the interpreting physician's recommendations.​

9.8.11.3 entry/procedure/code​

Vocabulary binding for Concept Domain Recommended Follow-up may be further profiled in sub-specialty guidelines.​

Note​

An example would be Value Set CID 6028 “Mammography Recommended Follow-up”, incorporating concepts from ACR​ BI-RADS ®.​

9.8.11.4 entry/procedure/effectiveTime​

The HL7v3 IVL <TS> Data Type used for effectiveTime requires the specification of absolute dates, rather than a date relative to the​ date of the report.​

Note​

Thus the concept "follow-up within one year" needs to be encoded as a IVL <TS> with an effectiveTime/high element value​ one year after the date of the report.​

9.8.11.5 entry/procedure/text/reference​

The procedure entry SHALL include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its​ corresponding narrative content block. See Section 9.1.1.1.​

Example 9.8.11-1. Radiology recommendation section example​

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.2.840.10008.9.12" />

<id root="1.2.840.10213.2.62.7044779.114265201"/> <code code="18783-1" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Study Recommendation"/> <title>Radiology Recommendation</title>

<text>

<content ID="rec01">Biopsy should be considered. Follow-up at 3 month interval. </content>

<linkHtml href="http://pubs.rsna.org/doi/abs/10.1148/radiol.2372041887"/> </text>

<entry>

<procedure ID="RadRec1" classCode="PROC" moodCode="PRP"/> <!-- local coding scheme -->

<code code="9191919" codeSystem="2.16.840.1.56789.6.1" codeSystemName="My Hospital Coding System" displayName="3 month follow-up"/>

<text><reference value="#rec01"/></text> <effectiveTime value="20141213"/>

</entry>

</section>

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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture​ Page 95​

10 Entry-level Templates​

10.1 Coded Observation​

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