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

Page 41​

codeSystem="2.16.840.1.123456.78.9" />

</code>

7.1.2 Addendum​

COND: If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator​ element (i.e., was signed), the component/structuredBody SHALL contain at least one 9.7 Addendum.​

7.2 Imaging Addendum Report​

Template ID​

1.2.840.10008.9.24​

Name​

Imaging Addendum Report​

Effective Date​

2015/03/24​

Version Label​

DICOM-20150324​

Status​

Active​

Description​

DocumentstructureforanImagingAddendumReport,i.e.,anappendagetoanexisting​

 

reportdocumentthatcontainssupplementalinformation.Theparentdocumentcontent​

 

remains unaltered. The Addendum Report must be read together with its parent​

 

document for full context. Some institutions may have policies that forbid the use of​

 

Addendum Reports, and require revised reports with a complete restatement of the​

 

original documentation.​

Classification​

CDA Document Level​

Relationships​

 

Context​

parent node​

Open/Closed​

Open​

Revision History​

DICOM-20150324: Initial version​

Business​

Nest​

Element/​

Card​

Elem/Attr​

Data​Value​

Value​

Subsidiary​

Name​

Level​

Attribute​

 

Conf​

Type​Conf​

 

Template​

Imaging​

 

Clinical​

 

 

 

 

 

 

Addendum​

 

Document​

 

 

 

 

 

 

 

>​

templateId​

1..1​

SHALL​

II​

 

 

 

 

>@​

@root​

1..1​

SHALL​

UID​

SHALL​1.2.840.10008.9.1​

 

DocType​

>​

code​

1..1​

SHALL​

CD​

SHALL​ValueSetLOINCImaging​

 

 

 

 

 

 

CWE​

Document Codes​

 

 

 

 

 

 

 

noNull​ 1.3.6.1.4.1.12009.10.2.5​

 

>​

 

1..1​

SHALL​

 

 

 

8.1GeneralHeader​

 

 

 

 

 

 

 

 

1.2.840.10008.9.20​

 

>​

 

1..1​

SHALL​

 

 

 

8.2ImagingHeader​

 

 

 

 

 

 

 

 

1.2.840.10008.9.21​

 

>​

relatedDocument​1..1​

SHALL​

 

 

 

 

 

>@​

@typecode​

1.1​

SHALL​

CS​

SHALL​APND​

 

 

>>​

parentDocument​1..1​

SHALL​

 

 

 

 

Amended​

>>>​

id​

1..1​

SHALL​

II​

 

 

 

DocumentID​

 

 

 

 

 

 

 

 

>​

component​

1..1​

SHALL​

 

 

 

 

 

>>​

structuredBody​1..1​

SHALL​

 

 

 

 

- Standard -​

Page 42​

 

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

 

Business​

Nest​

Element/​

Card​

Elem/Attr​

Data​Value​ Value​

Subsidiary​

Name​

Level​

Attribute​

 

Conf​

Type​Conf​

Template​

 

>>>​

component​

1..*​

SHALL​

 

 

Addendum[*]​>>>>​

section​

 

 

 

9.7 Addendum​

 

 

 

 

 

 

1.2.840.10008.9.6​

- Standard -​

DICOM PS3.20 2020a - Imaging Reports using HL7 Clinical Document Architecture​ Page 43​

8 Header Content Templates​

8.1 General Header​

Template ID​

 

 

 

1.2.840.10008.9.20​

 

 

 

Name​

 

 

 

General Header Elements​

 

 

Effective Date​

 

 

2015/03/24​

 

 

 

 

Version Label​

 

 

DICOM-20150324​

 

 

 

Status​

 

 

 

Active​

 

 

 

 

Description​

 

 

 

CDA Header Elements for all documents, including primary participations​

Classification​

 

 

CDA Header Elements​

 

 

Relationships​

 

 

Included in all document level templates​

 

 

Context​

 

 

 

sibling node​

 

 

 

Open/Closed​

 

 

Open​

 

 

 

 

Revision History​

 

 

DICOM-20150324: Initial version​

 

 

Business​

Nest​ Element/Attribute​ Card​

Elem/Attr​

Data​ Value​

Value​

Subsidiary​

Name​

Level​

 

 

Conf​

Type​ Conf​

 

Template​

 

 

templateId​

1..1​

SHALL​

II​

 

 

 

 

@​

@root​

1..1​

SHALL​

UID​

SHALL​1.2.840.10008.9.20​

 

Content​

 

templateId​

0..*​

MAY​

II​

 

 

 

Template​

 

 

 

 

 

 

 

 

 

 

typeId​

1..1​

SHALL​

II​

 

 

 

 

@​

@root​

1..1​

SHALL​

UID​

SHALL​2.16.840.1.113883.1.3​

 

 

@​

@extension​

1..1​

SHALL​

ST​

SHALL​POCD_HD000040​

 

 

 

id​

1..1​

SHALL​

II​

 

 

 

Title​

 

title​

1..1​

SHALL​

ST​

 

 

 

CreationTime​

effectiveTime​

1..1​

SHALL​

TS​

 

 

 

Confidentiality​

confidentialityCode​1..1​

SHALL​

CE​

SHALL​ValueSet​

 

 

 

 

 

 

 

 

CWE​ x_BasicConfidentialityKind​

 

 

 

 

 

 

 

Value Set​

 

 

 

 

 

 

 

2.16.840.1.113883.11.16926​

Language​

 

languageCode​

1..1​

SHALL​

CS​

SHALL​ValueSet CID 5000​

 

Code​

 

 

 

 

 

CNE​ “Languages”​

 

SetId​

 

setId​

0..1​

MAY​

II​

 

 

 

Version​

 

versionNumber​

1..1​

COND​

INT​

 

 

 

Number​

 

 

 

 

 

 

 

 

Patient[*]​

 

recordTarget​

1..*​

SHALL​

 

 

 

 

 

>​

patientRole​

1..1​

SHALL​

 

 

 

 

 

>>​

id​

1..*​

SHALL​

II​

 

 

 

IDIssuer​

>>@​

root​

1..1​

SHALL​

UID​

Issuer of Patient ID Qualifiers​

 

 

 

 

 

 

Sequence (0010,0024) >​

 

 

 

 

 

 

 

Universal Entity ID​

 

 

 

 

 

 

 

(0040,0032)​

 

Patient ID List PID-3.4.2​

- Standard -​

Page 44​

 

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

 

Business​

Nest​ Element/Attribute​ Card​

Elem/Attr​

Data​ Value​

Value​

Subsidiary​

Name​

Level​

 

Conf​

Type​ Conf​

 

Template​

ID​

>>@​

extension​

1..1​

SHALL​

ST​

Patient ID (0010,0020)​

 

 

 

 

 

 

 

Patient ID List PID-3.1​

 

Addr​

>>​

addr​

1..*​

SHALL​

AD​

 

 

 

Tele​

>>​

telecom​

1..*​

SHALL​

TEL​

 

 

 

 

>>​

patient​

1..1​

SHALL​

 

 

 

 

Name​

>>>​

name​

1..1​

SHALL​

PN​

Patient's Name (0010,0010)​

 

 

 

 

 

 

Patient Name PID-5​

 

Gender​

>>>​

administrative​

1..1​

SHALL​

CE​

SHALL​ValueSet​

 

 

 

 

GenderCode​

 

 

 

CNE​ AdministrativeGender Value​

 

 

 

 

 

 

Set 2.16.840.1.113883.11.1​

 

 

 

 

 

 

Patient's Sex (0010,0040);​

 

 

 

 

 

 

 

[Map value "O" to nullFlavor​

 

 

 

 

 

 

UNK]​

 

 

 

 

 

 

 

 

Administrative Sex PID-3.8​

 

BirthTime​

>>>​

birthTime​

1..1​

SHALL​

TS​

Patient's Birth Date​

 

 

 

 

 

 

 

(0010,0030) + Patient's Birth​

 

 

 

 

 

 

Time (0010,0032)​

 

 

 

 

 

 

 

Date/Time of Birth PID-7​

 

 

>>​

provider​

0..1​

MAY​

 

 

 

 

 

 

Organization​

 

 

 

 

 

 

ProviderOrg​ >>>​

name​

1..*​

SHALL​

ON​

Issuer of Patient ID​

 

Name​

 

 

 

 

 

(0010,0021)​

 

ProviderOrg​ >>>​

telecom​

0..*​

SHOULD​

TEL​

 

 

 

Tel​

 

 

 

 

 

 

 

 

ProviderOrg​ >>>​

addr​

0..*​

SHOULD​

AD​

 

 

 

Addr​

 

 

 

 

 

 

 

 

 

 

legalAuthenticator​0..1​

MAY​

 

 

 

 

SigningTime​>​

time​

1..1​

SHALL​

TS​

 

 

 

 

>​

signatureCode​

1..1​

SHALL​

CS​

SHALL​S​

 

 

 

>​

assignedEntity​

1..1​

SHALL​

 

 

 

 

SignerID​

>>​

id​

1.*​

SHALL​

II​

 

 

 

SignerAddr​

>>​

addr​

1.*​

SHALL​

AD​

 

 

 

SignerTel​

>>​

telecom​

1..*​

SHALL​

TEL​

 

 

 

 

>>​

assignedPerson​ 1..1​

SHALL​

 

 

 

 

SignerName​>>>​

name​

1..1​

SHALL​

PN​

 

 

 

Signature​

>​

sdtc:signatureText​0..1​

MAY​

ED​

 

 

 

Block​

 

 

 

 

 

 

 

 

Author[*]​

 

author​

1..*​

SHALL​

 

 

 

 

AuthoringTime​>​

time​

1..1​

SHALL​

TS​

 

 

 

 

>​

assignedAuthor​

1..1​

SHALL​

 

 

 

 

 

>>​

id​

1.*​

SHALL​

II​

 

 

 

Addr​

>>​

addr​

1.*​

SHALL​

AD​

 

 

 

- Standard -​

 

 

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

Page 45​

Business​

Nest​ Element/Attribute​ Card​

Elem/Attr​

Data​ Value​

Value​

Subsidiary​

Name​

Level​

 

Conf​

Type​ Conf​

 

Template​

Tel​

>>​

telecom​

1..*​

SHALL​

TEL​

 

 

 

>>​

assignedPerson​ 1..1​

SHALL​

 

 

 

Name​

>>>​

name​

1..1​

SHALL​

PN​

 

 

Recipient[*]​

 

information​

0..*​

MAY​

 

 

 

 

 

Recipient​

 

 

 

 

 

 

>​

intendedRecipient​1..1​

SHALL​

 

 

 

 

>@​

@classCode​

1..1​

SHALL​

CS​ SHALL​ASSIGNED​

 

Addr​

>>​

addr​

0.*​

MAY​

AD​

 

 

Tel​

>>​

telecom​

0..*​

MAY​

TEL​

 

 

 

>>​

information​

0..1​

MAY​

 

 

 

 

 

Recipient​

 

 

 

 

 

Name​

>>>​

name​

1..1​

SHALL​

PN​

 

 

 

>>​

received​

0..1​

MAY​

 

 

 

 

 

Organization​

 

 

 

 

 

Org​

>>>​

name​

1..1​

SHALL​

ON​

 

 

 

 

custodian​

1..1​

SHALL​

 

 

 

 

>​

assignedCustodian​1..1​

SHALL​

 

 

 

 

>>​

represented​

1..1​

SHALL​

 

 

 

 

 

Custodian​

 

 

 

 

 

 

 

Organization​

 

 

 

 

 

CustodianOrg​>>>​

id​

1.*​

SHALL​

II​

 

 

ID​

 

 

 

 

 

 

 

CustodianOrg​>>>​

name​

1..1​

SHALL​

ON​

 

 

Name​

 

 

 

 

 

 

 

CustodianOrg​>>>​

addr​

1..1​

SHALL​

AD​

 

 

Addr​

 

 

 

 

 

 

 

CustodianOrg​>>>​

telecom​

1..1​

SHALL​

TEL​

 

 

Tel​

 

 

 

 

 

 

 

Note that there is no business name associated with this template. Rather, this template is an editorial convenience for template​ specification, and the Business Names for the elements of this template are logically part of the business name scope of the invoking​ template.​

8.1.1 templateId - contentTemplate​

ThistemplateIdmaybeusedtoidentifythetemplate(s)usedtogenerate/constrainthecontentofthereport.Thiselementisinaddition​ to the templateId of the document level template, and typically represents clinical sub-specialty requirements. See Section 5.1.1 on​ the structure and use of the templateId.​

Note​

The IHE MRRT profile defines a "dcterms.identifier" that may be used for this templateId.​

8.1.2 title​

The title may include the title of the report template used.​

Note​

The IHE MRRT profile defines a "dcterms.title" that may be used in this element.​

- Standard -​

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