Материал: part20

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

Page 141​

SR Tree​Nesting​ Attribute​

Tag​ VR​VL​

Value​

 

Depth​

 

 

(hex)​

 

 

1.8.1​

%item​

 

 

 

 

1.8.1​

>>​

Relationship​

(0040,a010)​CS​0008​CONTAINS​

 

 

 

 

Type​

 

 

 

1.8.1​

>>​

Value Type​

(0040,a040)​CS​0004​TEXT​

 

 

1.8.1​

>>​

Concept Name​(0040,a043)​SQ​ffffffff​

 

 

 

 

Code Sequence​

 

 

1.8.1​

%item​

 

 

 

 

1.8.1​

>>>​

Code Value​

(0008,0100)​SH​0006​121071​

 

 

1.8.1​

>>>​

Coding Scheme​(0008,0102)​SH​0004​DCM​

 

 

 

 

Designator​

 

 

 

1.8.1​

>>>​

Code Meaning​ (0008,0104)​LO​0008​Finding​

 

 

1.8.1​

%enditem​

 

 

 

1.8.1​

%endseq​

 

 

 

1.8.1​

>>​

Text Value​

(0040,a160)​UT​01ae​The cardiomediastinum is within normal limits. The trachea is midline.​

 

 

 

The previously described opacity at the medial right lung base has​

 

 

 

cleared. There are no new infiltrates. There is a new round density at​

 

 

 

the left hilus, superiorly (diameter about 45mm). A CT scan is​

 

 

 

recommended for further evaluation. The pleural spaces are clear.​

 

 

 

The visualized musculoskeletal structures and the upper abdomen​

 

 

 

are stable and unremarkable.​

 

1.8.1​

>>​

Content​

(0040,a730)​SQ​ffffffff​

 

 

 

 

Sequence​

 

 

 

1.8.1.1​ %item​

 

 

 

 

1.8.1.1​ >>>​

Relationship​

(0040,a010)​CS​000e​INFERRED FROM​

 

 

 

 

Type​

 

 

 

1.8.1.1​ >>>​

Observation​

(0040,a032)​DT​000e​20060823223912​

 

 

 

 

DateTime​

 

 

 

1.8.1.1​ >>>​

Value Type​

(0040,a040)​CS​0004​NUM​

 

 

1.8.1.1​ >>>​

Concept Name​(0040,a043)​SQ​ffffffff​

 

 

 

 

Code Sequence​

 

 

1.8.1.1​ %item​

 

 

 

 

1.8.1.1​ >>>>​

Code Value​

(0008,0100)​SH​0008​81827009​

 

 

1.8.1.1​ >>>>​

Coding Scheme​(0008,0102)​SH​0004​SCT​

 

 

 

 

Designator​

 

 

 

1.8.1.1​ >>>>​

Code Meaning​ (0008,0104)​LO​0008​Diameter​

 

 

1.8.1.1​ %enditem​

 

 

 

1.8.1.1​ %endseq​

 

 

 

1.8.1.1​ >>>​

Measured Value​(0040,a300)​SQ​ffffffff​

 

 

 

 

Sequence​

 

 

 

1.8.1.1​ %item​

 

 

 

 

1.8.1.1​ >>>>​

Measurement​

(0040,08ea)​SQ​ffffffff​

 

 

 

 

Units Code​

 

 

 

 

 

Sequence​

 

 

 

1.8.1.1​ %item​

 

 

 

 

1.8.1.1​ >>>>>​

Code Value​

(0008,0100)​SH​0002​mm​

 

 

- Standard -​

Page 142​

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

SR Tree​Nesting​ Attribute​

Tag​ VR​VL​

Value​

Depth​

 

 

(hex)​

 

1.8.1.1​ >>>>>​

Coding Scheme​(0008,0102)​SH​0004​UCUM​

 

 

 

Designator​

 

 

1.8.1.1​ >>>>>​

Code Meaning​ (0008,0104)​LO​0002​mm​

 

1.8.1.1​ %enditem​

 

 

1.8.1.1​ %endseq​

 

 

1.8.1.1​ >>>>​

Numeric Value​ (0040,a30a)​DS​0002​45​

 

1.8.1.1​ %enditem​

 

 

1.8.1.1​ %endseq​

 

 

1.8.1.1​ >>>​

Content​

(0040,a730)​SQ​ffffffff​

 

 

 

Sequence​

 

 

1.8.1.1.1​%item​

 

 

 

1.8.1.1.1​>>>>​

ReferencedSOP​(0008,1199)​SQ​ffffffff​

 

 

 

Sequence​

 

 

1.8.1.1.1​%item​

 

 

 

1.8.1.1.1​>>>>>​

ReferencedSOP​(0008,1150)​UI​001a​1.2.840.10008.5.1.4.1.1.1​

 

 

 

Class UID​

 

 

1.8.1.1.1​>>>>>​

ReferencedSOP​(0008,1155)​UI​003c​1.2.840.113619.2.62.994044785528.20060823.200608232232322.3​

 

 

Instance UID​

 

 

1.8.1.1.1​%enditem​

 

 

1.8.1.1.1​%endseq​

 

 

1.8.1.1.1​>>>>​

Relationship​

(0040,a010)​CS​000e​INFERRED FROM​

 

 

 

Type​

 

 

1.8.1.1.1​>>>>​

Value Type​

(0040,a040)​CS​0006​IMAGE​

 

1.8.1.1.1​>>>>​

Concept Name​(0040,a043)​SQ​ffffffff​

 

 

 

Code Sequence​

 

1.8.1.1.1​%item​

 

 

 

1.8.1.1.1​>>>>>​

Code Value​

(0008,0100)​SH​0006​121112​

 

1.8.1.1.1​>>>>>​

Coding Scheme​(0008,0102)​SH​0004​DCM​

 

 

 

Designator​

 

 

1.8.1.1.1​>>>>>​

Code Meaning​ (0008,0104)​LO​0016​Source of Measurement​

 

1.8.1.1.1​%enditem​

 

 

1.8.1.1.1​%endseq​

 

 

1.8.1.1.1​%enditem​

 

 

1.8.1.1​ %endseq​

 

 

1.8.1.1​ %enditem​

 

 

1.8.1​

%endseq​

 

 

1.8.1​

%enditem​

 

 

1.8​

%endseq​

 

 

1.8​

%enditem​

 

 

1.9​

%item​

 

 

 

1.9​

>​

Relationship​

(0040,a010)​CS​0008​CONTAINS​

 

 

 

Type​

 

 

1.9​

>​

Value Type​

(0040,a040)​CS​000a​CONTAINER​

 

- Standard -​

 

 

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

Page 143​

SR Tree​Nesting​ Attribute​

Tag​ VR​VL​

Value​

 

Depth​

 

 

(hex)​

 

 

1.9​

>​

Concept Name​(0040,a043)​SQ​ffffffff​

 

 

 

 

Code Sequence​

 

 

1.9​

%item​

 

 

 

 

1.9​

>>​

Code Value​

(0008,0100)​SH​0006​121072​

 

 

1.9​

>>​

Coding Scheme​(0008,0102)​SH​0004​DCM​

 

 

 

 

Designator​

 

 

 

1.9​

>>​

Code Meaning​ (0008,0104)​LO​000c​Impressions​

 

 

1.9​

%enditem​

 

 

 

1.9​

%endseq​

 

 

 

1.9​

>​

Continuity Of​

(0040,a050)​CS​0008​SEPARATE​

 

 

 

 

Content​

 

 

 

1.9​

>​

Content​

(0040,a730)​SQ​ffffffff​

 

 

 

 

Sequence​

 

 

 

1.9.1​

%item​

 

 

 

 

1.9.1​

>>​

Relationship​

(0040,a010)​CS​0008​CONTAINS​

 

 

 

 

Type​

 

 

 

1.9.1​

>>​

Value Type​

(0040,a040)​CS​0004​TEXT​

 

 

1.9.1​

>>​

Concept Name​(0040,a043)​SQ​ffffffff​

 

 

 

 

Code Sequence​

 

 

1.9.1​

%item​

 

 

 

 

1.9.1​

>>>​

Code Value​

(0008,0100)​SH​0006​121073​

 

 

1.9.1​

>>>​

Coding Scheme​(0008,0102)​SH​0004​DCM​

 

 

 

 

Designator​

 

 

 

1.9.1​

>>>​

Code Meaning​ (0008,0104)​LO​000a​Impression​

 

 

1.9.1​

%enditem​

 

 

 

1.9.1​

%endseq​

 

 

 

1.9.1​

>>​

Text Value​

(0040,a160)​UT​009c​No acute cardiopulmonary process. Round density in left superior​

 

 

 

hilus, further evaluation with CT is recommended as underlying​

 

 

 

malignancy is not excluded.​

 

 

1.9.1​ %enditem​

1.9​ %endseq​

1.9​ %enditem​ 1​ %endseq​

C.5.2 Transcoded HL7 CDA Release 2 Imaging Report​

<?xml version="1.0" encoding="utf-8"?> <?xml-stylesheet type="text/xsl" href="CDA-DIR.xsl"?> <ClinicalDocument xmlns="urn:hl7-org:v3"

xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:ps3-20="urn:dicom-org:ps3-20" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">

<realmCode code="UV"/>

<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> <templateId root="1.2.840.10008.9.1"/>

<templateId root="1.2.840.10008.9.20"/> <templateId root="1.2.840.10008.9.21"/>

- Standard -​

Page 144​

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

<templateId root="1.2.840.10008.9.22"/>

<id root="1.2.840.113619.2.62.994044785528.12"extension="20060828170821659"/> <code code="18748-4" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Diagnostic Imaging Report"/> <title>Chest X-Ray, PA and LAT View</title>

<effectiveTime value="20060828170821"/>

<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US"/>

<recordTarget>

<patientRole>

<id root="1.2.840.113619.2.62.994044785528.10" extension="0000680029"/> <addr nullFlavor="NI"/>

<telecom nullFlavor="NI"/> <patient>

<name>

<given>John</given>

<family>Doe</family>

</name>

<administrativeGenderCode codeSystem="2.16.840.1.113883.5.1"code="M"/> <birthTime value="19641128"/>

</patient>

</patientRole>

</recordTarget>

<author>

<time value="20060823224352"/> <assignedAuthor>

<id extension="121008" root="2.16.840.1.113883.19.5"/> <addr nullFlavor="NI"/>

<telecom nullFlavor="NI"/> <assignedPerson>

<name>

<given>Richard</given>

<family>Blitz</family>

<suffix>MD</suffix>

</name>

</assignedPerson>

</assignedAuthor>

</author>

<custodian>

<!-- custodian values have been added based on organizational policy (int his case they are not mapped from the SR sample document) --> <assignedCustodian>

<representedCustodianOrganization>

<id root="2.16.840.1.113883.19.5"/> <name>World University Hospital</name> <telecom nullFlavor="NI"/>

<addr nullFlavor="NI"/> </representedCustodianOrganization>

</assignedCustodian>

</custodian>

<!-- legal authenticator present in sample, document is VERIFIED --> <legalAuthenticator>

<time value="20060827141500"/>

<!-- Verification DateTime (0040,A030) --> <signatureCode code="S"/> <assignedEntity>

<id extension="08150000" root="1.2.840.113619.2.62.994044785528.33"/> <addr nullFlavor="NI"/>

<telecom nullFlavor="NI"/> <assignedPerson>

- Standard -​

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

Page 145​

<name>

<given>Richard</given>

<family>Blitz</family>

<suffix>MD</suffix>

</name>

</assignedPerson>

</assignedEntity>

</legalAuthenticator>

<!-- Mapped from Referring Physician's Name (0008,0090) SR sample document --> <participant typeCode="REF">

<associatedEntity classCode="PROV"> <id nullFlavor="NI"/>

<addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <associatedPerson>

<name>

<given>John</given>

<family>Smith</family>

<suffix>MD</suffix>

</name>

</associatedPerson>

</associatedEntity>

</participant>

<inFulfillmentOf>

<order>

<id extension="123451" root="1.2.840.113619.2.62.994044785528.29"/> <ps3-20:accessionNumber extension="10523475"root="1.2.840.113619.2.62.994044785528.27"/>

</order>

</inFulfillmentOf>

<documentationOf>

<serviceEvent classCode="ACT">

<id root="1.2.840.113619.2.62.994044785528.114289542805"/> <!-- Study Instance UID -->

<code code="11123" codeSystem="1.2.840.113619.2.62.5661" codeSystemName="99WUHID" displayName="X-Ray Study"/>

<translation code="XR" displayName="XR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/>

<translation code="51185008" displayName="Chest" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>

<!-- anatomy code mapped from old style SNOMED in SR to new --> </code>

</code>

<effectiveTime>

<low value="20060823222400"/> </effectiveTime>

</serviceEvent>

</documentationOf>

<!-- transformation of a DICOM SR --> <relatedDocument typeCode="XFRM">

<parentDocument>

<id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9"/> <!-- SOP Instance UID (0008,0018) of SR sample document-->

</parentDocument>

</relatedDocument>

<component>

<structuredBody>

<component>

<!--**************** Clinical Information Section *****************--> <section>

<templateId root="1.2.840.10008.9.2"/>

- Standard -​

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