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

9.6 Impression

Template ID

1.2.840.10008.9.5

Name

Impression

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

The most important diagnoses or other clinical conclusions that can be made from the imaging observations and other clinical information are recorded here. This section may include recommendations for additional imaging tests or other actions, as well as global assessments, such as BI-RADS Categories or the equivalent.

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

Impression

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.5

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(19005-8, LOINC, "Impressions")

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

Communication​Of​Actionable​Findings

>>

section

1..1

SHALL

9.8.10 Communication of Actionable Findings 1.2.840.10008.9.11

>

component

0..1

MAY

Key​Images

>>

section

1..1

SHALL

9.8.6 Key Images 1.3.6.1.4.1.19376.​1.4.1.2.14

>

component

0..*

MAY

Recommendation

>>

section

1..1

SHALL

9.8.11 Recommendation 1.2.840.10008.9.12

>

entry

0..*

MAY

Coded​Observation

>>

observation

1..1

SHALL

CD

10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

Example 9.6-1. Impression section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.27"/>
    <id root="1.2.840.10213.2.62.994948294044785528.11422458954285205"/>
    <code code="19005-8"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Impressions"/>
    <title>Impression</title>
    <text>This exam identified ...</text>
    <!-- other sections and entries here -->
</section>

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