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

9.5 Findings

Template ID

2.16.840.1.113883.​10.20.6.1.2

Name

Findings

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

Records clinically significant observations confirmed or discovered during the procedure.

Classification

CDA Section Level

Relationships

Included in 7.1 Imaging Report

Context

parent node

Open/Closed

Open

Revision History

From Consolidated CDA r1.1

DICOM-20150324: Added optional subsections and entries

Business Name

Nest Level

Element/​Attribute

Card

Elem/Attr Conf

Data Type

Value Conf

Value

Subsidiary Template

Findings

section

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

2.16.840.1.113883.​10.20.6.1.2

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(59776-5, LOINC, "Procedure Findings")

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..*

MAY

Fetus​Findings[*]

>>

section

1..1

SHALL

9.8.8 Fetus Findings 1.2.840.10008.9.9

>

component

0..*

MAY

Subsection[*]

>>

section

1..1

SHALL

9.8.9 Labeled Subsection 1.2.840.10008.9.10

>

0..1

MAY

9.1.2 General Section Entries 1.2.840.10008.9.23

9.5.1 text

If entries are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text.

The narrative text associated with an actionable finding SHOULD be highlighted using styleCode Bold. See Section 9.1.1.1.

Actionable findings that require a specific follow-up action or procedure SHOULD be referenced from a recommendation in the 9.8.11 Recommendation section.

Communication of actionable findings SHOULD be documented in the 9.8.10 Communication of Actionable Findings section.

Example 9.5.1-1. Findings section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.6.1.2"/>
    <id root="1.2.840.10213.2.62.941494044785528.114289542452452805"/>
    <code code="59776-5" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Procedure Findings"/>
    <title>Findings</title>
    <text>
        <paragraph>
            <caption>Finding</caption>
            <content ID="Fndng2">The cardiomediastinum is... </content>
        </paragraph>
        <paragraph>
            <caption>Diameter</caption>
            <content ID="Diam2">45mm</content>
        </paragraph>
        ...
    </text>
    <entry>
        <templateId root="2.16.840.1.113883.10.20.6.2.12"/>
        ...
    </entry>
    <!-- see examples for other sections/entries -->
</section>

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