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

Page 101​

Revision History​

 

From IHE Cardiac Imaging Report Content Profile Supplement for Trial​

 

 

 

Implementation​

 

 

 

 

Business​ Nest​

Element/​

Card​

Elem/Attr​

Data​

Value​

Value​

Subsidiary​

Name​

Level​

Attribute​

 

Conf​

Type​

Conf​

 

Template​

Graphic[*]​

observation​

1..1​

SHALL​

 

 

 

 

 

 

Media​

 

 

 

 

 

 

 

@​

classCode​

1..1​

SHALL​

CS​

OBS​

 

 

 

@​

moodCode​

1..1​

SHALL​

CS​

EVN​

 

 

*​

@​

@ID​

1..1​

SHALL​

XML ID​

 

[See 5.3.4 XML ID]​

 

 

>​

templateId​

1..1​

SHALL​

II​

 

 

 

 

>@​

@root​

1..1​

SHALL​

UID​

SHALL​

1.3.6.1.4.1.19376.1.4.1.4.7​

 

 

>​

id​

1..1​

SHALL​

II​

 

 

 

Image​

>​

value​

1..1​

SHALL​

ED​

 

 

 

 

>@​

@representation​1..1​

SHALL​

CS​

SHALL​

B64​

 

MediaType​>@​

@mediaType​

1..1​

SHALL​

CS​

SHALL​

ValueSet ImageMediaType​

 

 

 

 

 

 

 

CNE​

Value Set​

 

 

 

 

 

 

 

2.16.840.1.113883.11.14839​

 

 

 

 

 

 

STATIC​

 

 

ImageURI​>>​

reference​

0..1​

MAY​

TEL​

 

 

 

10.3.1 observationMedia/@ID and Related Narrative Block Markup​

The ObservationMedia entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) used as a​ target of a<renderMultiMedia> element in the section/text narrative block of the parent section. See Section 9.1.1.3.​

10.3.2 value and Reference​

The value of type ED SHALL contain an in-line encoding of a graphic using base64. The <reference> element, if present, SHALL​ reference a URI for the same image as included in-line.​

Example 10.3-1. Observation Media activity example​

<observationMedia classCode="SBADM" moodCode="EVN" ID="obsMedia-1"> <templateId root="1.3.6.1.4.1.19376.1.4.1.4.7"/>

<id root="1.2.840.19432234.2342342.23232232"/> <value representation="B64" mediaType="image/jpeg">

Bgd3fsET4g...

</value>

</observationMedia>

10.4 Procedure Technique​

Template ID​

1.2.840.10008.9.14​

Name​

Procedure Technique​

Effective Date​

2015/03/24​

Version Label​

DICOM-20150324​

Status​

Active​

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Page 102​

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

Description​

The Procedure Technique entry allows the encoding of various parameters of​

 

theimageacquisition.Otherdetailsmaybefoundinotherentries(e.g.,procedural​

 

medication).​

Classification​

CDA Entry Level​

Relationships​

Included in 9.3 Imaging Procedure Description and 9.4 Comparison Study​

Context​

parent node​

Open/Closed​

Open​

Revision History​

DICOM-20150324: Initial version​

Business​

Nest​

Element/Attribute​ Card​

Elem/Attr Conf​Data Type​ Value​

Value​

Subsidiary​

Name​

Level​

 

 

 

 

Conf​

 

Template​

Procedure​

 

procedure​

1..1​

SHALL​

 

 

 

 

Technique​

 

 

 

 

 

 

 

 

 

@​

@classCode​

1..1​

SHALL​

CS​

SHALL​ PROC​

 

 

@​

@moodCode​

1..1​

SHALL​

CS​

SHALL​ EVN​

 

 

>​

templateId​

1..1​

SHALL​

II​

 

 

 

 

>@​

@root​

1..1​

SHALL​

UID​

 

1.2.840.10008.9.14​

 

>​

id​

1..1​

SHALL​

II​

 

 

 

Procedure​

>​

code​

1..1​

SHALL​

CD​

 

ConceptDomain​

 

Code​

 

 

 

 

 

 

ProcedureCode​

 

 

>​

text​

0..1​

SHOULD​

ED​

 

 

 

Ref​

>>​

reference​

1..1​

SHALL​

URL (XML​

# contentRef​

 

 

 

 

 

 

IDREF)​

 

 

 

EffectiveTime​>​

effectiveTime​

0..1​

SHOULD​

IVL <TS>​

 

 

 

Modality​

>​

methodCode​

1..*​

SHALL​

CD​

SHALL​

ValueSet CID 29​

 

 

 

 

 

 

 

CNE​

“Acquisition​

 

 

 

 

 

 

 

 

Modality”​

 

MethodCode​>​

methodCode​

0..*​

MAY​

CD​

 

ConceptDomain​

 

 

 

 

 

 

 

 

ImagingTechnique​

TargetSite​

>​

targetSiteCode​

0..*​

SHOULD​

CD​

 

ConceptDomain​

 

 

 

 

 

 

 

 

TargetSite​

 

 

>>​

qualifier​

0..1​

COND​

 

 

 

 

 

>>>​

name​

1..1​

SHALL​

CD​

SHALL​ (272741003,​

 

 

 

 

 

 

 

 

SNOMED CT,​

 

 

 

 

 

 

 

 

"laterality")​

 

Laterality​

>>>​

value​

1..1​

SHALL​

CD​

SHALL​

ValueSet CID 244​

 

 

 

 

 

 

 

CNE​

“Laterality”​

 

 

>​

participation​

0..1​

COND​

 

 

 

 

 

>@​

@typecode​

1..1​

SHALL​

CS​

SHALL​ LOC​

 

 

>>​

participantRole​

1..1​

SHALL​

 

 

 

 

 

>>@​

classCode​

1..1​

SHALL​

CS​

SHALL​ SDLOC​

 

 

>>>​

scopingEntity​

1..1​

SHALL​

 

 

 

 

Provider​

>>>>​

desc​

1..1​

SHALL​

ST​

 

 

 

Organization​

10.4.1 id​

procedure/id does not correspond to any DICOM UID, but is an arbitrary identifier for this entry.​

- Standard -​

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

Page 103​

10.4.2 code​

When invoked from the (current) 9.3 Imaging Procedure Description, procedure/code SHALL be identical to documentationOf/ser-​ viceEvent/code in the CDA header.​

10.4.3 text/reference and Related Narrative Block Markup​

The Procedure entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to​ its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.​

10.4.4 methodCode - Modality​

When invoked from the (current) 9.3 Imaging Procedure Description, procedure/methodCode used for modality SHALL be identical​ to documentationOf/serviceEvent/code/translation used for modality in the CDA header (see Section 8.2.4.1).​

10.4.5 methodCode - Other Parameters​

methodCode may be used to encode study type, contrast use, challenge, views, positioning (CID 91 “Functional Condition Present​ During Acquisition”, CID 92 “Joint Position During Acquisition”, CID 93 “Joint Positioning Method”, CID 94 “Physical Force Applied​ During Acquisition”), etc.​

10.4.6 targetSiteCode and Laterality​

procedure/targetSiteCodemaybeusedtoencodethespecificanatomicfocus,andisnotnecessarilyidenticaltodocumentationOf/ser-​ viceEvent/code/translation used for anatomic region in the CDA header. This may be derived from Body Part Examined (0018,0015),​ as mapped to SNOMED codes in Annex L “Correspondence of Anatomic Region Codes and Body Part Examined Defined Terms” in​ PS3.16, or from Anatomic Region Sequence (0008,2218).​

COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not​ pre-coordinated in the targetSiteCode.​

10.4.7 participation - Location​

COND: If this template is invoked from the Comparison Study section, procedure/participation MAY be used to identify the location​ (provider organization) at which the Comparison Study was performed.​

Example 10.4-1. Procedure Technique template example​

<procedure moodCode="EVN" classCode="PROC"> <templateId root="1.2.840.10008.9.14"/>

<id root="1.2.840.6544.33.9100653988998717.997527582345600170"/> <code code="RPID465"

displayName="MR NECK ANGIOGRAPHY" codeSystem="2.16.840.1.113883.6.256" codeSystemName="RadLex"/>

<text><reference value="#proc"/></text> <effectiveTime value="20140913222400"/> <methodCode code="MR"

displayName="Magnetic Resonance" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/>

<targetSiteCode code="45048000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Neck (structure)">

</targetSiteCode>

</procedure>

- Standard -​

Page 104​ DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture​

10.5 Quantity Measurement​

Template ID​

 

 

2.16.840.1.113883.10.20.6.2.14​

 

 

Name​

 

 

Quantity Measurement​

 

 

 

Effective Date​

 

 

2015/03/24​

 

 

 

 

Version Label​

 

 

DICOM-20150324​

 

 

 

 

Status​

 

 

Active​

 

 

 

 

 

Description​

 

 

AQuantityMeasurementrecordsquantitativemeasurementssuchaslinear,area,volume,​

 

 

 

and numeric measurements. If based on image data, a reference to the image may be​

 

 

 

present.​

 

 

 

 

 

Classification​

 

 

CDA Entry Level​

 

 

 

 

Relationships​

 

 

 

 

 

 

 

 

Context​

 

 

parent node​

 

 

 

 

Open/Closed​

 

 

open​

 

 

 

 

 

Revision History​

 

DICOM-20150324: Initial publication, derived from template originally published in DIR​

 

 

 

r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.14. This​

 

 

 

derivation includes Units of Measure specified with DICOM value set for UCUM (CID 82​

 

 

 

“UnitsofMeasurement”),equivalenttoC-CDAspecifiedvalueset(UCUMUnitsofMeasure​

 

 

 

(casesensitive)2.16.840.1.113883.11.12839);additionofoptionalinterpretationCodeand​

 

 

 

actionable priority​

 

 

 

 

Business Name​Nest​

Element/​

Card​

Elem/Attr​ Data​

Value​

Value​

Subsidiary​

 

Level​ Attribute​

 

Conf​

Type​

Conf​

 

Template​

Quantity​

 

observation​ 1..1​

SHALL​

 

 

 

 

Measurement[*]​

 

 

 

 

 

 

 

 

@​

@classCode​1..1​

SHALL​

CS​

SHALL​ OBS​

 

 

@​

@moodCode​1..1​

SHALL​

CS​

SHALL​ EVN​

 

 

>​

templateId​

1..1​

SHALL​

II​

 

 

 

 

>@​

@root​

1..1​

SHALL​

UID​

SHALL​ 2.16.840.1.113883.​

 

 

 

 

 

 

 

 

10.20.6.2.14​

 

 

>​

id​

1..1​

SHALL​

II​

 

 

 

Measurement​

>​

code​

1..1​

SHALL​

CD​

 

ConceptDomain​

 

Name​

 

 

 

 

 

 

ObservationType​

 

 

>​

text​

0..1​

SHOULD​

 

 

 

 

Ref​

>>​

reference​

1..1​

SHALL​

URL​

 

# contentRef​

 

 

 

 

 

 

(XML​

 

 

 

 

 

 

 

 

IDREF)​

 

 

 

>​

statusCode​ 1..1​

SHALL​

CS​

SHALL​ COMPLETED​

 

Time​

>​

effectiveTime​0..1​

SHOULD​ TS​

 

 

 

 

>​

value​

1..1​

SHALL​

 

 

 

 

 

>@​

@xsi:type​

1..1​

SHALL​

ST​

SHALL​ PQ​

 

Measurement​

>@​

@value​

1..1​

SHALL​

REAL​

 

 

 

Value​

 

 

 

 

 

 

 

 

Measurement​

>@​

@unit​

1..1​

SHALL​

CS​

SHALL​ ValueSet CID 82 “Units of​

 

Units​

 

 

 

 

 

CNE​

Measurement”​

 

 

 

 

 

 

 

 

 

- Standard -​

 

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

Page 105​

Business Name​Nest​

Element/​

Card​

Elem/Attr​ Data​

Value​

Value​

Subsidiary​

 

Level​ Attribute​

 

Conf​

Type​

Conf​

 

Template​

Interpretation​

>​

interpretation​0..1​

MAY​

CE​

SHALL​ ValueSet​

 

Code​

 

Code​

 

 

 

CNE​

ObservationInterpretation​

 

 

 

 

 

 

 

Value Set​

 

 

 

 

 

 

 

 

2.16.840.1.113883.11.78​

ActionablePriority​>>​

translation​

1..1​

MAY​

CD​

MAY​

ValueSet CID 7035​

 

 

 

 

 

 

 

CWE​

“Actionable Finding​

 

 

 

 

 

 

 

 

Classification”​

 

 

 

 

 

 

 

 

[See 10.1.3​

 

 

 

 

 

 

 

 

interpretationCode and​

 

 

 

 

 

 

 

 

translation For Actionable​

 

 

 

 

 

 

 

Findings]​

 

TargetSite​

>​

targetSite​

1..1​

COND​

CD​

 

ConceptDomain​

 

 

 

Code​

 

 

 

 

ObservationSite​

 

 

>>​

qualifier​

0..1​

COND​

 

 

 

 

 

>>>​

name​

1..1​

SHALL​

CD​

SHALL​ (272741003, SNOMED​

 

 

 

 

 

 

 

 

CT, "laterality")​

 

Laterality​

>>>​

value​

1..1​

SHALL​

CD​

SHALL​ ValueSet CID 244​

 

 

 

 

 

 

 

CNE​

“Laterality”​

 

 

>>​

qualifier​

0..1​

COND​

 

 

 

 

 

>>>​

name​

1..1​

SHALL​

CD​

SHALL​ (106233006, SNOMED​

 

 

 

 

 

 

 

 

CT, "Topographical​

 

 

 

 

 

 

 

 

modifier")​

 

TopoModifier​

>>>​

value​

1..1​

SHALL​

CD​

SHALL​ ValueSetCID2“Anatomic​

 

 

 

 

 

 

CNE​

Modifier”​

 

Method​

>​

methodCode​0..1​

MAY​

CD​

 

ConceptDomain​

 

 

 

 

 

 

 

 

ObservationMethod​

 

 

>​

entry​

0..*​

MAY​

 

 

 

 

 

 

Relationship​

 

 

 

 

 

 

 

>@​

@typeCode​ 1..1​

SHALL​

CS​

SHALL​ SPRT​

 

SOPInstance[*]​>>​

observation​

1..1​

SHALL​

 

 

 

10.8 SOP Instance​

 

 

 

 

 

 

 

 

Observation​

 

 

 

 

 

 

 

 

1.2.840.10008.9.18​

 

>​

entry​

0..*​

MAY​

 

 

 

 

 

 

Relationship​

 

 

 

 

 

 

 

>@​

@typeCode​ 1..1​

SHALL​

CS​

SHALL​ SPRT​

 

Quantity​

>​

observation​

1..1​

SHALL​

 

 

 

10.5 Quantity​

Measurement[*]​

 

 

 

 

 

 

Measurement​

 

 

 

 

 

 

 

 

2.16.840.1.113883.​

 

 

 

 

 

 

 

 

10.20.6.2.14​

10.5.1 text/reference and Related Narrative Block Markup​

The Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element​ oftheObservationclass)SHALLbeginwitha'#'andSHALLpointtoitscorrespondingnarrativeintheparentsection(usingtheapproach​ defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.​

- Standard -​

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