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

9.2 Clinical Information

Template ID

1.2.840.10008.9.2

Name

Clinical Information

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc.

Classification

CDA Section Level

Relationships

Included in 7.1 Imaging Report

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

Clinical​Information

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.2

>

id

1..1

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(55752-0, LOINC, "Clinical Information")

Title

>

title

1..1

SHALL

ST

Text

>

text

1..1

COND

ED

9.1.1 Section Text 1.2.840.10008.9.19

>

component

0..1

MAY

Request

>>

section

1..1

SHALL

9.8.1 Request 1.2.840.10008.9.7

>

component

0..1

MAY

Procedure​Indications

>>

section

1..1

SHALL

9.8.2 Procedure Indications 1.2.840.10008.9.22

>

component

0..1

MAY

History

>>

section

1..1

SHALL

9.8.3 Medical (General) History 2.16.840.1.113883.​10.20.22.2.39

>

0..1

MAY

9.1.2 General Section Entries 1.2.840.10008.9.23

Example 9.2-1. Clinical Information section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="1.2.840.10008.9.2"/>
    <id root="1.2.840.10213.2.62.994044785528.114289542805"/>
    <code code="55752-0" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Clinical Information"/>
    <title>Clinical Information</title>
    <text>The patient was referred for evaluation of suspected pulmonary embolism.</text>
    <!---see examples for other sections/entries -->
</section>

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