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

9.3 Imaging Procedure Description

Template ID

1.2.840.10008.9.3

Name

Imaging Procedure Description

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

The Imaging Procedure Description section records the technical details of the procedure and may include information about protocol, imaging device, contrast, radiation dose, medications administered (sedation, stress agents), 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

Procedure​Description

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.3

>

id

1..1

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(55111-9, LOINC, "Current Imaging Procedure Description")

Title

>

title

1..1

SHALL

ST

Text

>

text

1..1

COND

ED

9.1.1 Section Text 1.2.840.10008.9.19

>

entry

1..1

SHALL

Procedure​Technique

>>

procedure

1..1

SHALL

10.4 Procedure Technique 1.2.840.10008.9.14

>

entry

0..*

MAY

Procedural​Medication[*]

>>

substance​Administration

1..1

SHALL

10.2 Procedural Medication 1.2.840.10008.9.13

>

component

0..1

MAY

Complications

>>

section

1..1

SHALL

9.8.4 Complications 2.16.840.1.113883.​10.20.22.2.37

>

component

0..1

COND

Radiation​Exposure

>>

section

1..1

SHALL

9.8.5 Radiation Exposure and Protection Information 1.2.840.10008.9.8

>

component

1..1

SHALL

DICOMObject​Catalog

>>

section

1..1

SHALL

9.8.7 DICOM Object Catalog 2.16.840.1.113883.​10.20.6.1.1

>

entry

0..1

MAY

Image​Quality

>>

observation

1..1

SHALL

10.9 Image Quality 1.2.840.10008.9.15

Example 9.3-1. Current Imaging Procedure description section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="1.2.840.10008.9.3"/>
    <id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/>
    <code code="55111-9" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Current Imaging Procedure Description"/>
    <title>Imaging Procedure Description</title>
    <text>A CT study was acquired with 2.5 mm images of the abdomen and pelvis with 140 ml of... </text>
    <!-- See Procedure Technique template example - required here -->
    <!-- See DICOM Imaging Catalog template example - required here -->
    <!---see examples for other sections/entries -->
</section>

9.3.1 component/section Radiation Exposure and Protection Information

COND: If the documented service utilizes ionizing radiation, a 9.8.5 Radiation Exposure and Protection Information section MAY be present.

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