DICOM PS3.20 2019a - Imaging Reports using HL7 Clinical Document Architecture

7 Document-level Templates

Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and sections by referring to templates, and constraints on the vocabulary used in those templates.

7.1 Imaging Report

Template ID

1.2.840.10008.9.1

Name

Imaging Report

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

This CDA Imaging Report document template defines the report content and technical constraints for top level elements, attributes, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or therapeutic radiology, cardiology, or other imaging reports.

The body of an Imaging Report may contain five main imaging report sections:

  • Clinical information (optionally);

  • Current imaging procedure description;

  • Comparison studies (optionally);

  • Findings (optionally);

  • Impression;

  • plus potentially an Addendum(s)

The report templates sponsored by the RSNA Radiology Reporting Initiative (http://www.radreport.org) adhere to this general section outline.

The section and subsection structure of this template is also identified by LOINC panel code 87416-4.

Classification

CDA Document Level

Relationships

Context

parent node

Open/Closed

Open

Revision History

DICOM-20150324: Initial version

Business Name

Nest Level

Element/​Attribute

Card

Elem/Attr Conf

Data Type

Value Conf

Value

Subsidiary Template

Imaging​Report

Clinical​Document

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.1

Doc​Type

>

code

1..1

SHALL

CD

SHALL CWE noNull

ValueSet LOINC Imaging Document Codes 1.3.6.1.4.1.12009.10.2.5

>

1..1

SHALL

8.1 General Header 1.2.840.10008.9.20

>

1..1

SHALL

8.2 Imaging Header 1.2.840.10008.9.21

>

0..1

MAY

8.3 Parent Document 1.2.840.10008.9.22

>

component

1..1

SHALL

>>

structured​Body

1..1

SHALL

>>>

component

0..1

MAY

Clinical​Information

>>>>

section

9.2 Clinical Information 1.2.840.10008.9.2

>>>

component

1..1

SHALL

Procedure​Description

>>>>

section

9.3 Imaging Procedure Description 1.2.840.10008.9.3

>>>

component

0..1

MAY

Comparison​Study

>>>>

section

9.4 Comparison Study 1.2.840.10008.9.4

>>>

component

0..1

MAY

Findings

>>>>

section

9.5 Findings 2.16.840.1.113883.​10.20.6.1.2

>>>

component

1..1

SHALL

Impression

>>>>

section

9.6 Impression 1.2.840.10008.9.5

>>>

component

0..*

COND

Addendum[*]

>>>>

section

9.7 Addendum 1.2.840.10008.9.6

7.1.1 clinicalDocument/code

Most of the codes in Value Set LOINC Imaging Document Codes are pre-coordinated with the imaging modality, body part examined, and/or specific imaging method. When pre-coordinated codes are used, any coded values elsewhere in the document describing the modality, body part, etc., must be consistent with the document type code. Local codes used for report types may be included as a translation element in the code.

Note

Use of Value Set LOINC Imaging Document Codes is harmonized with HL7 Consolidated CDA Templates for Clinical Notes, Release 2. DICOM CID 7001 “Diagnostic Imaging Report Headings”, used in TID 2000 “Basic Diagnostic Imaging Report”, is a subset of the LOINC Imaging Document Codes.

Example 7.1.1-1. clinicalDocument/code example with translation element for local code

<code code="18748-4"
        displayName="Diagnostic Imaging Report"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" >
    <translation code="XRPEDS"
        displayName="Pediatric Radiography Report"
        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.

DICOM PS3.20 2019a - Imaging Reports using HL7 Clinical Document Architecture