Материал: part20

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1 Scope and Field of Application​

ThisPartoftheDICOMStandardspecifiestemplatesfortheencodingofimagingreportsusingtheHL7ClinicalDocumentArchitecture​ Release 2 (CDA R2, or simply CDA) Standard. Within this scope are clinical procedure reports for specialties that use imaging for​ screening, diagnostic, or therapeutic purposes.​

This Part constitutes an implementation guide for CDA, and is harmonized with the approach to standardized templates for CDA im-​ plementation guides developed by HL7. It also provides Business Names for data elements that link data in user terminology, e.g.,​ collected by a report authoring application, to specific CDA encoded elements.​

As an implementation guide for imaging reports, particular attention is given to the use and reference of data collected in imaging​ proceduresasexplicitevidencewithinreports.Thisdataincludesimages,waveforms,measurements,annotations,andotheranalytic​ results managed as DICOM SOP Instances. Specifically, this Part includes a specification for transformation into CDA documents of​ DICOM Structured Report instances that represent imaging reports.​

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2 Normative and Informative References​

The following standards contain provisions that, through reference in this text, constitute provisions of this Standard. At the time of​ publication, the editions indicated were valid. All standards are subject to revision, and parties to agreements based on this Standard​ are encouraged to investigate the possibilities of applying the most recent editions of the standards indicated below.​

[ISO/IEC Directives, Part 2] ISO/IEC. 2016/05. 7.0. Rules for the structure and drafting of International Standards. http://www.iec.ch/​ members_experts/refdocs/iec/isoiecdir-2%7Bed7.0%7Den.pdf .​

ANSI/HL7 CDA®, R2-2005 HL7 Version 3 Standard: Clinical Document Architecture (CDA) Release 2, 2005 (http://www.hl7.org/​ implement/standards/product_brief.cfm?product_id=7)​

CDA® is a registered trademark of HL7 International.​

ANSI/HL7 V3 CPPV3MODELS, R1-2012 HL7 Version 3 Standard: Core Principles and Properties of Version 3 Models, Release 1​ (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=58)​

ANSI/HL7 V3 CMET, R2-2009 Health Level Seven Version 3 Standard: Common Message Element Types, Release 2, 2009.​

ANSI/HL7V3DT,R1-2004HL7Version3DataTypesAbstractSpecification,Release1-November2004.[Note:thisspecificrelease​ version is required by CDA R2]​

ANSI/HL7 V3 XMLITSDT, R1-2004 HL7 Version 3 XML Implementation Technology Specification - Data Types, Release 1 - April​ 2004. [Note: this specific release version is required by CDA R2]​

HL7 CDA R2 DIR IG, R1-2009 Health Level Seven Implementation Guide for CDA Release 2: Imaging Integration, Basic Imaging​ Reports in CDA and DICOM, Diagnostic Imaging Reports (DIR) Release 1.0 - Informative, 2009 (http://www.hl7.org/implement/​ standards/product_brief.cfm?product_id=13)​

HL7 CDAR2_IG_IHE_CONSOL HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1.1 - US​ Realm, Draft Standard for Trial Use, July 2012 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258)​

HL7 CDAR2_IG_CCDA_CLINNOTES_R2 HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical​ Notes,Release2-USRealm,DraftStandardforTrialUse,November2014(http://www.hl7.org/implement/standards/product_brief.cfm?​ product_id=379)​

HL7 CDAR2_IG_GREENMOD4CCD HL7 Implementation Guides for CDA® R2: greenCDA Modules for CCD®, Release 1 - Inform-​ ative, April 2011(http://www.hl7.org/implement/standards/product_brief.cfm?product_id=136)​

HL7 Templates HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1 - DSTU,​ October 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=377)​

HL7 CDA Digital Signatures HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights, Release​ 1 - DSTU, October 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=375)​

HL7 v3-2014 HL7 Version 3 Interoperability Standards, Normative Edition 2014 (http://www.hl7.org/implement/standards/​ product_brief.cfm?product_id=362]​

IHE Card Sup CIRC IHE Cardiology Technical Framework Supplement, Cardiac Imaging Report Content, Trial Implementation, July​ 2011 (http://www.ihe.net/Technical_Frameworks/#cardiology)​

IHE ITI TF IHE IT Infrastructure Technical Framework, Revision 11.0, September 2014 (http://www.ihe.net/Technical_Frameworks/​ #IT)​

IHE PCC TF IHE Patient Care Coordination Technical Framework, Revision 10.0, November 2014 (http://www.ihe.net/​ Technical_Frameworks/#pcc)​

IHE RAD TF IHE Radiology Technical Framework, Revision 13.0, July 2014 (http://www.ihe.net/Technical_Frameworks/#radiology)​

LOINC Logical Observation Identifier Names and Codes, Regenstrief Institute, Indianapolis 2013.​

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This product includes all or a portion of the LOINC® table, LOINC panels and forms file, LOINC document ontology file, and/or LOINC​ hierarchies file, or is derived from one or more of the foregoing, subject to a license from Regenstrief Institute, Inc. Your use of the​ LOINC table, LOINC codes, LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file also is subject​ to this license, a copy of which is available at http://loinc.org/terms-of-use. The current complete LOINC table, LOINC Users' Guide,​ LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file are available for download at http://loinc.org.​ The LOINC table and LOINC codes are copyright © 1995-2013, Regenstrief Institute, Inc. and the Logical Observation Identifiers​ Names and Codes (LOINC) Committee. The LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies​ file are copyright © 1995-2013, Regenstrief Institute, Inc. All rights reserved.​

THE LOINC TABLE (IN ALL FORMATS), LOINC PANELS AND FORMS FILE, LOINC DOCUMENT ONTOLOGY FILE, AND LOINC​ HIERARCHIES ARE PROVIDED "AS IS." ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT​ LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.​

LOINC® is a registered United States trademark of Regenstrief Institute, Inc. A small portion of the LOINC table may include content​ (e.g., survey instruments) that is subject to copyrights owned by third parties. Such content has been mapped to LOINC terms under​ applicable copyright and terms of use. Notice of such third party copyright and license terms would need to be included if such content​ is included.​

RFC4646 Tags for Identifying Languages, The Internet Society, 2005​

SNOMED CT® Systematized Nomenclature of Medicine - Clinical Terms, International Release, International Health Terminology​ Standards Development Organisation (IHTSDO), January 2015​

SNOMED CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).​

UCUM Unified Code for Units of Measure, Regenstrief Institute, Indianapolis 2013.​

This product includes all or a portion of the UCUM table, UCUM codes, and UCUM definitions or is derived from it, subject to a license​ from Regenstrief Institute, Inc. and The UCUM Organization. Your use of the UCUM table, UCUM codes, UCUM definitions also is​ subjecttothislicense,acopyofwhichisavailableathttp://unitsofmeasure.org.ThecurrentcompleteUCUMtable,UCUMSpecification​ are available for download at http://unitsofmeasure.org. The UCUM table and UCUM codes are copyright © 1995-2013, Regenstrief​ Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved.​

THE UCUM TABLE (IN ALL FORMATS), UCUM DEFINITIONS, AND SPECIFICATION ARE PROVIDED "AS IS." ANY EXPRESS​ ORIMPLIEDWARRANTIESAREDISCLAIMED,INCLUDING,BUTNOTLIMITEDTO,THEIMPLIEDWARRANTIESOFMERCHANT-​ ABILITY AND FITNESS FOR A PARTICULAR PURPOSE.​

XML Extensible Markup Language (XML) 1.0 (Fifth Edition), World Wide Web Consortium, 2008 (http://www.w3.org/TR/REC-xml/)​

XML Schema Datatypes XML Schema Part 2: Datatypes Second Edition, World Wide Web Consortium, 2004 (http://www.w3.org/TR/​ xmlschema-2/)​

xml:id xml:id Version 1.0, World Wide Web Consortium, 2005 (http://www.w3.org/TR/xml-id)​

XPath XML Path Language (XPath), Version 1.0, World Wide Web Consortium, 1999 (http://www.w3.org/TR/xpath/)​

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