Материал: part20
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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<code code="55752-0" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Clinical Information" |
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<title>Clinical Information</title> |
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<component> |
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<!--**************** Procedure Indications Subsection ***************** |
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Section text mapped from "Reason for the Requested Procedure" (0040,1002) |
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within the Referenced Request Sequence (0040,A370) of the SR header, under |
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the assumption that the header attribute value has been displayed to, and |
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accepted by, the legal authenticator.--> |
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<section> |
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<templateId root="2.16.840.1.113883.10.20.22.2.29"/> |
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<id root="1.2.840.10213.2.62.044785528.1142895426"/> |
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<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" |
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codeSystemName="LOINC" displayName="Procedure Indications"/> |
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<title>Indications for Procedure</title> |
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<text>Suspected lung tumor</text> |
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</section> |
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<!--**************** End of Procedure Indications Subsection *****************--> |
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</component> |
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<component> |
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<!--**************** History Subsection *****************--> |
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<section> |
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<templateId root="2.16.840.1.113883.10.20.22.2.39"/> |
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<id root="1.2.840.10213.2.62.7044785528.114289875"/> |
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<code code="11329-0" codeSystem="2.16.840.1.113883.6.1" |
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codeSystemName="LOINC" displayName="History General"/> |
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<title>History</title> |
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<text> |
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<paragraph> |
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<caption>History</caption> |
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<content ID="Fndng1">Sore throat.</content> |
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</paragraph> |
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</text> |
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<entry> |
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<!-- History report element (TEXT) --> |
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<observation classCode="OBS" moodCode="EVN"> |
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<templateId root="2.16.840.1.113883.10.20.6.2.12"/> |
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<code code="121060" codeSystem="1.2.840.10008.2.16.4" |
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codeSystemName="DCM" displayName="History"/> |
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<value xsi:type="ED"> |
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<reference value="#Fndng1"/> |
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</value> |
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</observation> |
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</entry> |
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</section> |
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<!--**************** End of History Subsection *****************--> |
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</component> |
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<!--**************** End of Clinical Information Section *****************--> |
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</component> |
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<component> |
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<!--**************** Imaging Procedure Description Section *****************--> |
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<section classCode="DOCSECT" moodCode="EVN"> |
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<templateId root="1.2.840.10008.9.3"/> |
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<id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/> |
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<code code="55111-9" codeSystem="2.16.840.1.113883.6.1" |
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codeSystemName="LOINC" displayName="Current Imaging Procedure Description"/> |
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<title>Imaging Procedure Description</title> |
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<text> </text> |
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<entry> |
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<procedure moodCode="EVN" classCode="PROC"> |
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<templateId root="1.2.840.10008.9.14"/> |
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture Page 147
<id root="1.2.840.6544.33.9100653988998717.997527582345600170"/> <code code="11123" displayName="X-Ray Study" codeSystem="1.2.840.113619.2.62.5661" codeSystemName="99WUHID"/> <effectiveTime value="20060823222400"/>
<methodCode code="XR" displayName="XR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/> <targetSiteCode code="51185008" displayName="Chest" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</procedure>
</entry>
<component>
<!--**************** DICOM Object Catalog Sub-section *****************--> <section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.1.1"/> <code code="121181" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="DICOM Object Catalog"/> <entry>
<!--**************** Study *****************--> <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"/>
<!--**************** Series (Parent SR Document) *****************--> <entryRelationship typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<id root="1.2.840.113619.2.62.994044785528.20060823222132232023"/> <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">
</name>
<value code="CR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="SR Document">
</value>
</qualifier>
</code>
<!--**************** SOP Instance UID *****************--> <!-- Reference to SR Document -->
<entryRelationship typeCode="COMP">
<observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8"/> <id
root="1.2.840.113619.2.62.994044785528.20060823.200608242334312.3"/> <code code="1.2.840.10008.5.1.4.1.1.88.22"codeSystem="1.2.840.10008.2.6.
codeSystemName="DCMUID"displayName="Enhanced SR"> </code>
<text mediaType="application/dicom">
<reference value="http://www.example.org/wado?requestType=WADO &studyUID=1.2.840.113619.2.62.994044785528.114289542805 &seriesUID=1.2.840.113619.2.62.994044785528.2006082322213223 &objectUID=1.2.840.113619.2.62.994044785528.20060823.2006082 &contentType=application/dicom"/>
<!--reference to image 1 (PA) --> </text>
<effectiveTime value="20060823223232"/> </observation>
</entryRelationship>
</act>
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture |
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</entryRelationship> |
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<!--**************** Series (CR Images) *****************--> |
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<entryRelationship typeCode="COMP"> |
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<act classCode="ACT" |
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moodCode="EVN"> |
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<id root="1.2.840.113619.2.62.994044785528.20060823223142485051"/> |
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<code code="113015" codeSystem="1.2.840.10008.2.16.4" |
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codeSystemName="DCM" displayName="Series"> |
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<qualifier> |
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<name code="121139" codeSystem="1.2.840.10008.2.16.4" |
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codeSystemName="DCM" displayName="Modality"> |
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</name> |
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<value code="CR" codeSystem="1.2.840.10008.2.16.4" |
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codeSystemName="DCM" displayName="Computed Radiography"> |
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</value> |
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</qualifier> |
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</code> |
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<!--**************** SOP Instance UID *****************--> |
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<!-- 2 References (chest PA and LAT) --> |
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<entryRelationship typeCode="COMP"> |
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<observation classCode="DGIMG" moodCode="EVN"> |
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<templateId root="2.16.840.1.113883.10.20.6.2.8"/> |
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<id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/> |
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<code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1" |
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codeSystemName="DCMUID"displayName="Computed Radiography Image Storage"> |
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</code> |
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<text mediaType="application/dicom"> |
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<reference value="http://www.example.org/wado?requestType=WADO |
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&studyUID=1.2.840.113619.2.62.994044785528.114289542805 |
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&seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051 |
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&objectUID=1.2.840.113619.2.62.994044785528.20060823.20060823223 |
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&contentType=application/dicom"/> |
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<!--reference to image 1 (PA) --> |
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</text> |
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<effectiveTime value="20060823223232"/> |
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</observation> |
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</entryRelationship> |
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<entryRelationship typeCode="COMP"> |
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<observation classCode="DGIMG" moodCode="EVN"> |
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<templateId root="2.16.840.1.113883.10.20.6.2.8"/> |
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<id root="1.2.840.113619.2.62.994044785528.20060823.200608232231422.3"/> |
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<code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1" |
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codeSystemName="DCMUID"displayName="Computed Radiography Image Storage"> |
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</code> |
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<text |
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mediaType="application/dicom"> |
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<reference value="http://www.example.org/wado?requestType=WADO |
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&studyUID=1.2.840.113619.2.62.994044785528.114289542805 |
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&seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051 |
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&objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232231422 |
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&contentType=application/dicom"/> |
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<!--reference to image 2 (LAT) --> |
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</text> |
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<effectiveTime value="20060823223142"/> |
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</observation> |
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</entryRelationship> |
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</act> |
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</entryRelationship> |
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</act> |
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</entry> |
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DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture Page 149
</section>
<!--**************** End of DICOM Object Catalog Subsection *****************--> </component>
</section>
<!--**************** End of Imaging Procedure Description Section *****************--> </component>
<component>
<!--**************** Findings Section *****************--> <section>
<templateId root="2.16.840.1.113883.10.20.6.1.2"/>
<id root="1.2.840.10213.2.62.9940434234785528.114289545000804445"/>
<code code="59776-5" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Findings"/> <title>Findings</title>
<text>
<paragraph>
<caption>Finding</caption>
<content ID="Fndng2">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.</content>
</paragraph>
<paragraph>
<caption>Diameter</caption> <content ID="Diam2">45mm</content>
</paragraph>
<paragraph>
<caption>Source of Measurement</caption> <content ID="SrceOfMeas2">
<linkHtml
href="http://www.example.org/wado?requestType=WADO
&studyUID=1.2.840.113619.2.62.994044785528.114289542805
&seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
&objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3 &contentType=application/dicom">Chest_PA</linkHtml>
</content>
</paragraph>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN"> <!-- Text Observation -->
<templateId root="2.16.840.1.113883.10.20.6.2.12"/>
<code code="121071" codeSystem="1.2.840.10008.2.16.4"codeSystemName="DCM" displayName="Finding"/ <value xsi:type="ED">
<reference value="#Fndng2"/> </value>
<!-- inferred from measurement --> <entryRelationship typeCode="SPRT">
<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/>
<code code="246120007" codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED" displayName="Nodule size">
<originalText>
<reference value="#Diam2"/> </originalText>
</code>
<!-- no DICOM attribute <statusCode code="completed"/> --> <effectiveTime value="20060823223912"/>
<value xsi:type="PQ" value="45" unit="mm"/> <!-- inferred from image -->
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<entryRelationship typeCode="SUBJ"> |
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<observation classCode="DGIMG" moodCode="EVN"> |
|
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<templateId root="2.16.840.1.113883.10.20.6.2.8"/> |
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<!-- (0008,1155) Referenced SOP Instance UID--> |
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<id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/> |
|
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<!-- (0008,1150) Referenced SOP Class UID --> |
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<code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1" |
|
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codeSystemName="DCMUID"displayName="Computed Radiography Image Storage"> |
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</code> |
|
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<text mediaType="application/dicom"> |
|
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<!--reference to CR DICOM image (PA view) --> |
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<reference |
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value="http://www.example.org/wado?requestType=WADO |
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|
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&studyUID=1.2.840.113619.2.62.994044785528.114289542805 |
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&seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051 |
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&objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3 |
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</text> |
&contentType=application/dicom"/> |
<effectiveTime value="20060823223232"/> <!-- Purpose of Reference --> <entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.9"/>
<code code="ASSERTION"codeSystem="2.16.840.1.113883.5.4"/>
<value xsi:type="CD" code="121112"codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"displayName="Source of Measurement">
<originalText>
<reference value="#SrceOfMeas2" />
</originalText>
</value>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
<!--**************** End of Findings Section *****************--> </component>
<component>
<!--**************** Impressions Section *****************--> <section>
<templateId root="1.2.840.10008.9.5"/>
<id root="1.2.840.10213.2.62.9940434234785528.114289545345927752"/>
<code code="19005-8" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Impressions"/> <title>Impressions</title>
<text>
<paragraph>
<caption>Impression</caption>
<content ID="Fndng3">No acute cardiopulmonary process. Round density in left superior hilus, further evaluation with CT is recommended as underlying malignancy is not excluded.</content>
</paragraph>
</text>
<entry>
<!-- Impression report element (TEXT) --> <observation classCode="OBS" moodCode="EVN">
<!-- Text Observation -->
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