DICOM PS3.20 2016e - Imaging Reports using HL7 Clinical Document Architecture


DICOM PS3.20 2016e - Imaging Reports using HL7 Clinical Document Architecture

DICOM Standards Committee

Table of Contents

Notice and Disclaimer
1. Scope and Field of Application
2. Normative and Informative References
3. Definitions
3.1. Codes and Controlled Terminology Definitions:
3.2. Vocabulary Model Definitions:
3.3. Template Definitions
3.4. Imaging Report Definitions
4. Symbols and Abbreviations
5. Conventions
5.1. Template Metadata
5.1.1. Template IDs and Version
5.1.2. Context
5.1.3. Open and Closed Templates
5.2. Template Table Structure
5.2.1. Business Name Multiple Instantiations Implicit Element Structure For Business Name
5.2.2. Nesting Level
5.2.3. Element/Attribute Names and XPath Notation
5.2.4. Cardinality
5.2.5. Element/Attribute Conformance
5.2.6. Data Type
5.2.7. Value Conformance
5.2.8. Value Specification Coded Simple Value Concept Descriptor and Coded With Equivalents Value Set Concept Domains Mapping From DICOM SOP Instances and HL7v2 Messages
5.2.9. Subsidiary Templates Vocabulary Binding and Constraints
5.2.10. Additional Requirements
5.3. Encoding
5.3.1. Translation Code Element
5.3.2. Null Flavor
5.3.3. Unknown Information
5.3.4. XML ID
5.4. Extension and Namespace
5.5. Serialization Order of Elements
6. Conformance
7. Document-level Templates
7.1. Imaging Report
7.1.1. clinicalDocument/code
7.1.2. Addendum
7.2. Imaging Addendum Report
8. Header Content Templates
8.1. General Header
8.1.1. templateId - contentTemplate
8.1.2. title
8.1.3. effectiveTime
8.1.4. setID and versionNumber
8.1.5. recordTarget/patientRole
8.1.6. legalAuthenticator
8.1.7. recordTarget/patientRole/Patient/birthTime
8.1.8. author/assignedAuthor
8.1.9. InformationRecipient/intendedRecipient
8.2. Imaging Header
8.2.1. componentOf/encompassingEncounter
8.2.2. Physician of Record Participant
8.2.3. inFulfillmentOf/Order and @ID
8.2.4. documentationOf/serviceEvent code and translation Performer
8.3. Parent Document
8.3.1. relatedDocument
8.3.2. parentDocument/setId and versionNumber
9. Section-level Templates
9.1. General Requirements For Sections
9.1.1. Section Text <content> Markup and Links From Entries <linkHtml> Markup and Internal References <renderMultiMedia> Markup and Graphical Content <linkHtml> Markup and External References <linkHtml> Markup and Image References list table
9.1.2. General Section Entries templateId author section/entry regionOfInterest
9.2. Clinical Information
9.3. Imaging Procedure Description
9.3.1. component/section Radiation Exposure and Protection Information
9.4. Comparison Study
9.5. Findings
9.5.1. text
9.6. Impression
9.7. Addendum
9.7.1. author
9.7.2. component/section - Communication of Actionable Findings
9.8. Sub-sections
9.8.1. Request text/content and @ID – CDS Record
9.8.2. Procedure Indications entry/observation
9.8.3. Medical (General) History section/text
9.8.4. Complications
9.8.5. Radiation Exposure and Protection Information text entry/procedure Patient Exposure entry/observation SOP Instance entry/observation Pregnancy entry/observation Indication entry/observation Dose Measurements
9.8.6. Key Images Section/text SOP Instance Observation observationMedia
9.8.7. DICOM Object Catalog
9.8.8. Fetus Findings name - FetusID
9.8.9. Labeled Subsection title component/section Labeled Subsection
9.8.10. Communication of Actionable Findings section/text/content - narrative entry/act entry/act/effectiveTime entry/act/participant
9.8.11. Recommendation text/content entry/procedure entry/procedure/code entry/procedure/effectiveTime entry/procedure/text/reference
10. Entry-level Templates
10.1. Coded Observation
10.1.1. code and @negationInd
10.1.2. text/reference and Related Narrative Block Markup
10.1.3. interpretationCode and translation For Actionable Findings
10.1.4. targetSiteCode
10.1.5. entryRelationship/@typeCode=SUBJ/observation - Coded
10.2. Procedural Medication
10.2.1. Business Name Alias
10.2.2. text/reference and Related Narrative Block Markup
10.2.3. doseQuantity
10.3. observationMedia
10.3.1. observationMedia/@ID and Related Narrative Block Markup
10.3.2. value and Reference
10.4. Procedure Technique
10.4.1. id
10.4.2. code
10.4.3. text/reference and Related Narrative Block Markup
10.4.4. methodCode - Modality
10.4.5. methodCode - Other Parameters
10.4.6. targetSiteCode and Laterality
10.4.7. participation - Location
10.5. Quantity Measurement
10.5.1. text/reference and Related Narrative Block Markup
10.5.2. interpretationCode and Translation For Actionable Findings
10.5.3. targetSiteCode
10.6. Study Act
10.6.1. entryRelationship/act - Series
10.7. Series Act
10.8. SOP Instance Observation
10.8.1. entryRelationship entryRelationship/@typeCode=SUBJ (SOP Instance) entryRelationship/@typeCode=RSON (Purpose of Reference) entryRelationship/@typeCode=COMP (Referenced Frames)
10.9. Image Quality
10.9.1. text/reference and Related Narrative Block Markup
A. SR Diagnostic Imaging Report Transformation Guide
B. SR Diagnostic Imaging Report Transformation Guide
C. SR to CDA Imaging Report Transformation Guide
C.1. Constraints
C.2. Conventions
C.3. Header Transformation
C.4. Body Transformation
C.4.1. Section Mapping
C.4.1.1. Section Observer Context
C.4.1.2. Comparison Study Procedure Context
C.4.1.3. Fetus Subject Context
C.4.2. Section/text
C.4.3. Content Item Mapping
C.4.3.1. Coded Observations
C.4.3.2. Text Observations
C.4.3.3. Image Observations
C.4.3.4. Numeric Observations
C.4.3.5. Inferred From Image Observations
C.4.3.6. Inferred From Numeric Observations
C.4.3.7. Inferred From Spatial Coordinates Observations
C.4.4. Specific Section Content Mapping
C.4.4.1. Procedure Indications
C.4.4.2. Current Procedure Descriptions
C.4.4.3. Radiation Exposure and Protection Information
C.4.4.4. Key Images
C.5. Example
C.5.1. DICOM SR "Basic Diagnostic Imaging Report" (TID 2000)
C.5.2. Transcoded HL7 CDA Release 2 Imaging Report

List of Figures

C-1. TID 2000 Structure Summarized from PS3.16, and mapping to CDA

List of Tables

5.1-1. Template metadata table format
5.2-1. Template table format
5.2.3-1. Template element and attribute example Vocabulary Binding Table Format
Cardiac Measurements
Current Lesion Sizes with Comparison to Exam on 2014/11/16
C.3-1. CDA Header content from SR
C.4-1. SR Section mapping to CDA
C.4-2. CDA Section mapping from SR
C.4-3. CDA Section author mapping from SR
C.4-4. Comparison Study mapping from SR
C.4-5. CDA Fetus subject mapping from SR
C.4-6. CDA Coded Observation mapping from SR CODE
C.4-7. CDA Coded Observation mapping from SR TEXT
C.4-8. CDA SOP Instance Observation mapping from SR IMAGE
C.4-9. CDA Quantity Measurement mapping from SR NUM
C.4-10. Clinical Information Procedure Indications mapping from SR
C.4-11. Current Procedure Description mapping from SR
C.4-12. CDA Radiation Exposure and Protection Information mapping from SR
C.4-13. Key Image mapping from SR
C.5-1. Sample document encoding

List of Examples Example Business Name based production logic with discriminators for two measurements
5.2.3-1. XML document example
5.3.1-1. Translation code example
5.3.2-1. nullFlavor example
5.3.2-2. XML example of allowed nullFlavors when element is required
5.3.3-1. Unknown medication example
5.3.3-2. Unknown medication use of anticoagulant drug example
5.3.3-3. No known medications example
7.1.1-1. clinicalDocument/code example with translation element for local code
8.1.5-1. Header example
8.1.6-1. legalAuthenticator example
8.1.7-1. recordTarget example
8.1.8-1. Person author example
8.1.9-1. informationRecipient example
8.2.1-1. componentOf example
8.2.2-1. Physician of record participant example
8.2.3-1. inFulfillmentOf example documentationOf example Physician reading study performer example participant example dataEnterer example
8.3.2-1. relatedDocument example Example - linkHtml references at point of use for RadLex Example- linkHtml references at end of narrative block for RadLex Example linkHtml reference for WADO image access Measurements Table Example 1 Measurements Table Example 2 Author example
9.2-1. Clinical Information section example
9.3-1. Current Imaging Procedure description section example
9.4-1. Comparison study section example
9.5.1-1. Findings section example
9.6-1. Impression section example
9.7.2-1. Addendum section example Request section example Procedure indications section example Medical (General) History section example
9.8.4-1. Complications section example Radiation Exposure and Protection section example
9.8.6-1. Key Images section example
9.8.7-1. DICOM object catalog section example
9.8.8-1. Fetus Findings section example Labeled sub-section example
9.8.10-1. Communication of Actionable Results section example
9.8.11-1. Radiology recommendation section example
10.1-1. Coded observation example
10.2-1. Procedural Medication activity example
10.3-1. Observation Media activity example
10.4-1. Procedure Technique template example
10.5-1. Quantity measurement observation example 1
10.5-2. Quantity measurement observation example 2
10.6-1. Study act example
10.7-1. Series act example
10.8-1. SOP instance observation example with purpose of reference
10.9-1. Image Quality example
DICOM PS3.20 2016e - Imaging Reports using HL7 Clinical Document Architecture