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

8.2 Imaging Header

Template ID

1.2.840.10008.9.21

Name

Imaging Header Elements

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

CDA Header Elements for imaging reports, including encounter, order, and study context

Classification

CDA Header Elements

Relationships

Included in 7.1 Imaging Report

Context

sibling 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

template​Id

1..1

SHALL

II

@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.21

component​Of

1..1

SHALL

>

encompassing​Encounter

1..1

SHALL

>>

id

0..1

SHOULD

II

Encounter​IDIssuer

>>@

@root

1..1

SHALL

UID

Issuer of Admission ID Sequence (0038;0014) > Universal Entity ID (0040,0032)

Visit Number PV1-19.4.2

Encounter​ID

>>@

@extension

1..1

SHALL

ST

Admission Id (0038,0010)

Visit Number PV1-19.1

Encounter​Time

>>

effective​Time

1..1

SHALL

>>

location

0..1

MAY

>>>

health​Care​Facility

1..1

SHALL

>>>>

location

0..1

SHOULD

Healthcare​Facility​Name

>>>>>

name

1..1

SHALL

EN

Healthcare​Facility​Address

>>>>>

addr

1..1

SHALL

AD

>>>>

service​Provider​Organization

0..1

SHOULD

Healthcare​Provider​Organization​Name

>>>>>

name

1..1

SHALL

ON

>>

encounter​Participant

0..*

MAY

>>@

@typeCode

1..1

SHALL

ATND

>>>

assigned​Entity

1..1

SHALL

>>>>

assigned​Person

1..1

SHALL

Attending​Physician​Name

>>>>>

name

1..1

SHALL

EN

in​Fulfillment​Of

1..*

SHALL

Order[*]

>

order

1..1

SHALL

>>

id

1..1

SHALL

II

Order​Assigning​Authority

>>@

@root

1..1

SHALL

UID

Order Placer Identifier Sequence (0040,0026) > Universal Entity ID (0040,0032)

Placer Order Number OBR-2.3

Order​Placer​Number

>>@

@extension

1..1

SHALL

ST

Placer Order Number/Imaging Service Request (0040,2016)

Placer Order Number OBR-2.1

>>

ps3-20:accessionNumber

1..1

SHALL

II

Accession​Assigning​Authority

>>@

@root

1..1

SHALL

UID

Issuer of Accession Number Sequence (0008,0051) > Universal Entity ID (0040,0032)

Filler Order Number OBR-2.3

Accession​Number

>>@

@extension

1..1

SHALL

ST

Accession Number (0008,0050)

Filler Order Number OBR-2.1

Ordered​Procedure​Code

>>

code

0..1

SHOULD

CE

Requested Procedure Code Sequence (0032,1064)

Universal Service ID OBR-4

Order​Priority

>>

priority​Code

0..1

SHOULD

CE

ValueSet ActPriority Value Set 2.16.840.1.113883.11.16866

documentation​Of

1..*

SHALL

Study[*]

>

service​Event

1..1

SHALL

Study​UID

>>

id

1..1

SHALL

II

Study Instance UID (0020,000D)

Study Instance UID IPC-3

Procedure​Code

>>

code

1..1

SHALL

CE

Procedure Code Sequence (0008,1032)

Modality

>>>

translation

1..*

SHALL

CD

SHALL CNE

Modality (0008,0060)

Anatomic​Region​Code

>>>

translation

0..1

SHOULD

CD

Concept​Domain AnatomicRegion

>>

effective​Time

1..1

SHALL

IVL <TS>

Study​Time

>>>

low

1..1

SHALL

TS

Study Date (0008,0020) + Study Time (0008,0030) + Timezone Offset From UTC (0008,0201)

Observation Date/Time OBR-7

Performer[*]

>>

performer

0..*

MAY

Type

>>@

@typeCode

1..1

SHALL

CS

SHALL

ValueSet x_serviceEventPerformer Value Set 2.16.840.1.113883.11.19601

>>>

assigned​Entity

1..1

SHALL

ID

>>>>

id

1..1

SHALL

II

>>>>

assigned​Person

1..1

SHALL

Name

>>>>>

name

1..1

SHALL

PN

participant

1..1

SHALL

@

@typeCode

1..1

SHALL

CS

SHALL

REF

>

associated​Entity

1..1

SHALL

>@

@classCode

1..1

SHALL

CS

SHALL

PROV

Referrer​ID

>>

id

0..1

SHOULD

II

Ordering Provider ORC-12.1 + ORC-12.9.2

Referrer​Addr

>>

addr

0.*

SHOULD

AD

Ordering Provider Address ORC-24

Referrer​Tel

>>

telecom

0..*

SHOULD

TEL

Call Back Phone Number ORC-14

>>

associated​Person

1..1

SHALL

Referrer​Name

>>>

name

1..1

SHALL

PN

Referring Physician's Name (0008,0090)

Ordering Provider ORC-12

data​Enterer

0..1

MAY

@

@typeCode

1..1

SHALL

CS

SHALL

ENT

>

assigned​Entity

1..1

SHALL

Transcriptionist​ID

>>

id

0..1

SHOULD

II

Transcriptionist OBR-35.1.1

>>

assigned​Person

0..1

SHOULD

Transcriptionist​Name

>>>

name

1..1

SHALL

PN

Transcriptionist OBR-35.1

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.

8.2.1 componentOf/encompassingEncounter

The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, Visit Number, or Admission ID, equivalent to DICOM attribute (0038,0010), that number should be present as the ID of the encompassingEncounter.

The effectiveTime of the encompassingEncounter represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.

Example 8.2.1-1. componentOf example

<componentOf>
    <encompassingEncounter>
        <id extension="9937012" root="1.3.6.4.1.4.1.2835.12"/>
        <effectiveTime value="20060828170821"/>
        <encounterParticipant typeCode="ATND">
            <assignedEntity>
                <id extension="4" root="2.16.840.1.113883.19"/>
                <code code="208M00000X"
                    codeSystem="2.16.840.1.113883.6.101"
                    codeSystemName="NUCC"
                    displayName="Hospitalist"/>
                <addr nullFlavor="NI"/>
                <telecom nullFlavor="NI"/>
                <assignedPerson>
                    <name>
                        <prefix>Dr.</prefix>
                        <given>Fay </given>
                        <family>Family</family>
                    </name>
                </assignedPerson>
            </assignedEntity>
        </encounterParticipant>
    </encompassingEncounter>
</componentOf>

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