Материал: part20

10.5.2 interpretationCode and Translation For Actionable Findings​

When a measurement is out of normal range, it may be flagged using the interpretationCode. Very abnormal values, often denoted​ as exceeding "panic limits", or as "actionable" or "critical findings", may have values such as (LL, ObservationInterpretation, "low​ alert"), (HH, ObservationInterpretation, "high alert"), or (AA, ObservationInterpretation, "abnormal alert").​

The translation element of the interpretationCode may be used to provide a further classification as defined in a regionallyor profes-​ sionally-specified value set. This template identifies an optional value set for the ACR Actionable Finding categories 1, 2, and 3, as​ defined by: Larson PA, et al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016.​

The narrative text associated with the 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.​

10.5.3 targetSiteCode​

Each observation needs to fully specify its site/location.​

COND:Iftheobservationsiteisnotpre-coordinatedintheobservation/code,itSHALLbespecifiedintheobservation/targetSiteCode.​

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.​

COND: The qualifier element for topographical modifier SHALL be present if the targetSiteCode does not fully specify the observation​ location in sufficient detail.​

Note​

Inclusion of a site name in a labeled subsection title (see Section 9.8.9) does not imply a finding site for observations within​ that subsection. The title is not semantically part of the post-coordination, and target sites must be explicitly identified.​

See Example 10.5-2 “Quantity measurement observation example 2”, an example of a measurement using a topographical​ modifier qualifier.​

Example 10.5-1. Quantity measurement observation example 1​

<text> ...

<content ID="Q21" styleCode="Bold">Calcium score (Agatston) : 817 [HIGH - ACR Cat3]</content>

...

</text>

<entry>

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <id root="1.2.840.10213.2.62.7044234.11652014"/>

<code code="112058" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Calcium score" />

<text><reference value="#Q21"/></text> <statusCode code="COMPLETED"/> <effectiveTime value="20140913223912"/>

<value xsi:type="PQ" unit="[arb'U]" value="817" /> <interpretationCode code="HH" codeSystem="2.16.840.1.113883.5.83"

codeSystemName="ObservationInterpretation" displayName="High alert"> <translation code="RID49482" codeSystem="2.16.840.1.113883.6.256"

codeSystemName="RADLEX" displayName="ACR Category 3 Actionable Finding" /> </interpretationCode>

<methodCode code="112055" codeSystem="1.2.840.10008.2.16.4"

- Standard -​

codeSystemName="DCM" displayName="Agatston" />

<!-- entryRelationships to SOP Instance Observations may go here --> </observation>

</entry>

Example 10.5-2. Quantity measurement observation example 2​

<section>

<title>Left femoral artery</title> <text>

...

<content ID="M10">Distal lumen stenosis: 75%</content>

...

</text>

<entry>

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <id root="1.2.840.10213.2.62.7044234.988810005"/>

<code code="408714007" codeSystem="2.16.840.1.113883.6.96" codeSystemName=" SNOMED CT"

displayName="Vessel lumen diameter reduction" /> <text><reference value="#M10"/></text>

<statusCode code="COMPLETED"/> <effectiveTime value="20140913223912"/> <value xsi:type="PQ" unit="%" value="75" /> <targetSiteCode code="113270003"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left femoral artery">

<qualifier>

<name code="106233006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Topographical modifier" />

<value code="46053002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Distal" />

</qualifier>

</targetSiteCode>

</observation>

</entry>

</section>

10.6 Study Act​

- Standard -​

10.6.1 entryRelationship/act - Series​

COND: If this template is invoked by the 9.8.7 DICOM Object Catalog, the entryRelationship to the Series act SHALL be present,​ otherwise it MAY be present.​

- Standard -​

Example 10.6-1. Study act example​

<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"/> <effectiveTime value="20060823223232"/>

<!-- **** Series ****--> <entryRelationship typeCode="COMP">

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

...

</act>

</entryRelationship>

</act>

10.7 Series Act​

- Standard -​

Example 10.7-1. Series act example​

<act classCode="ACT" moodCode="EVN"> <templateId root="1.2.840.10008.9.17"/>

<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"> <qualifier>

<name code="121139" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"

displayName="Modality"/>

<value code="CR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"

displayName="Computed Radiography"/> </qualifier>

</code>

<!-- **** SOP Instance UID *** --> <entryRelationship typeCode="COMP">

<observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/>

...

</observation>

</entryRelationship>

</act>

10.8 SOP Instance Observation​

- Standard -​