Материал: part20

CDA Template 1.2.840.10008.9.1 requires a minimum of an Imaging Procedure Description section and an Impression section.​

The section/code element shall be populated in accordance with the relevant CDA template; note that the code might not be the same​ as the Concept Name code of the SR section CONTAINER. The title element of each CDA section shall be populated as shown in​ Table C.4-2.​

Table C.4-2. CDA Section mapping from SR​

SR allows sections to be qualified by observation context, using TID 1001 and its subsidiary templates. This capability is constrained​ in this mapping.​

C.4.1.1 Section Observer Context​

TID 1002 Observer Context allows identification of a human or device author.​

Table C.4-3. CDA Section author mapping from SR​

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C.4.1.2 Comparison Study Procedure Context​

TID 1005 Procedure Context allows identification of a different procedure than the procedure identified in the SR Study IE as the​ context for the section observations. In the transformations of this Annex, only an identified comparison procedure is supported as​ ProcedureContext,theSRsectionbeingtransformedmustbeeitherPriorProcedureDescriptionsorPreviousFindings,andtheCDA​ section shall be in accordance with the Comparison Study section Template 1.2.840.10008.9.4.​

SR Instances using TID 2006 have additional attributes of a comparison procedure specified using TID 2007, which is used in the​ Prior Procedure Descriptions section. The attributes of both TID 1005 and TID 2007 are source data in the Table C.4-4 mapping.​

Table C.4-4. Comparison Study mapping from SR​

C.4.1.3 Fetus Subject Context​

TID1006SubjectContextallowsidentificationofadifferentsubjectthanthepatientidentifiedintheSRPatientIE.Inthetransformations​ ofthisAnnex,onlyanidentifiedfetussubjectissupportedasSubjectContextforaFindingssection.AnSRsectionwithafetussubject​ context shall be mapped to a CDA section shall be in accordance with the Fetus Findings subsection Template 1.2.840.10008.9.9.​ This section is subsidiary to the top level Findings section; multiple SR fetus findings sections may be mapped to separate CDA Fetus​ Findings subsections.​

Table C.4-5. CDA Fetus subject mapping from SR​

C.4.2 Section/text​

DICOM TID 2002 Report Narrative specifies that sections contain imaging report elements of type CODE, TEXT, IMAGE, or NUM.​

Section/text in the CDA document contains the narrative text (attested content) of the document. Section/text shall be generated from​ all the Content Items subsidiary to a section CONTAINER of the SR document, such that the full meaning is be conveyed in an un-​ ambiguous manner in the narrative block.​

The narrative rendered from each Content Item shall be encapsulated in a <content> element of the narrative block, allowing the as-​ sociated entry to reference it.​

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C.4.3 Content Item Mapping​

Each Content Item immediately subsidiary to a section CONTAINER shall be mapped to the corresponding entry level template, and​ shallbeincludedsubsidiarytotheassociatedCDAsectionorsubsection.Thisisinadditiontoitsrenderinginthesection/textnarrative​ block.​

Coded concepts that are encoded in the SR using with the Coding Scheme Designator "SRT" shall be mapped to the equivalent​ SNOMED CT code. Mappings for value sets invoked in both SR and CDA are provided in PS3.16.​

C.4.3.1 Coded Observations​

SR CODE Content Items shall be mapped to Coded Observation entries.​

Table C.4-6. CDA Coded Observation mapping from SR CODE​

TheCODEobservationsinTID2002donotspecificallyincludefindingsite,laterality,andtopographicalmodifiers,butthesemodifiers​ are not forbidden in the template, and may be present in a SR SOP Instance being transformed to CDA.​

C.4.3.2 Text Observations​

SR TEXT Content Items are mapped to Coded Observation entries, but the code is a nullFlavor with the text content in originalText.​

Table C.4-7. CDA Coded Observation mapping from SR TEXT​

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C.4.3.4 Numeric Observations​

SR NUM Content Items shall be mapped to Quantity Measurement entries.​

Table C.4-9. CDA Quantity Measurement mapping from SR NUM​

The SR templates invoked for NUM measurements from TID 2000 do not specifically include finding site, laterality, and topographical​ modifiers, but these modifiers are not forbidden in the template, they are used in many other NUM value templates (e.g., TID 300​ Measurement), and may be present in a SR SOP Instance being transformed to CDA.​

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C.4.3.5 Inferred From Image Observations​

SR TID 2001 and TID 2002 allow Content Items to be INFERRED FROM IMAGE observations. The INFERRED FROM relationship​ ismappedtotheentryRelationshipwithtypeCode=SPRT,andtheIMAGEobservationismappedtoaCDASOPInstanceObservation​ entry subsidiary to its parent CDA Coded Observation or Quantity Measurement entry. This entryRelationship is shown in the Coded​ Observation and Quantity Measurement CDA Templates.​

C.4.3.6 Inferred From Numeric Observations​

SR TID 2001 and TID 2002 allow Content Items to be INFERRED FROM NUM observations. The INFERRED FROM relationship is​ mapped to the entryRelationship with typeCode=SPRT, and the NUM observation is mapped to CDA Quantity Measurement entry​ subsidiary to its parent CDA Coded Observation or Quantity Measurement entry. This entryRelationship is shown in the Coded Ob-​ servation and Quantity Measurement CDA Templates.​

C.4.3.7 Inferred From Spatial Coordinates Observations​

SR TID 1400, TID 1401, TID 1402, and TID 1404 allow NUM Content Items to be INFERRED FROM SCOORD observations, which​ areSELECTEDFROMIMAGEobservations.ThisAnnexdoesnotspecifythetransformationforSCOORDobservations;thesewould​ use the CDA Region Of Interest entry, which PS3.20 forbids (see Section 9.1.2.4).​

C.4.4 Specific Section Content Mapping​

Certain sections in a CDA Imaging Report have specific mappings from the DICOM SR header, or from specialized templates with​ content for particular uses.​

C.4.4.1 Procedure Indications​

The DICOM SR Document General Module may specify the Reason for the Requested Procedure as either free text in attribute​ (0040,1002), and/or as multiple coded values in attribute (0040,100A). These are mapped to the Procedure Indications subsection​ of the Clinical Information section of the CDA Imaging Report.​

Note​

ProcedureindicationsmayalsobespecifiedasSRcontentitemsinthe(18785-6,LN,"IndicationsforProcedure")CONTAINER,​ which may be mapped to the CDA instance in accordance with Section C.4.3. It is an implementation decision how to handle​ multiple representations of indications in the SR document.​

Table C.4-10. Clinical Information Procedure Indications mapping from SR​

C.4.4.2 Current Procedure Descriptions​

SR Instances using TID 2006 have a Current Procedure Descriptions section specified using TID 2007. Source data in that template​ and from the General Study Module is mapped into the CDA Procedure Description section.​

Table C.4-11. Current Procedure Description mapping from SR​

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