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

9.8.10 Communication of Actionable Findings

Template ID

1.2.840.10008.9.11

Name

Communication of Actionable Findings

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

A section that documents the notification of an actionable finding to a provider or other person responsible for patient care. The documentation in narrative text, and optionally in a coded entry, includes by whom, to whom, and at what date/time.

Specific findings, including actionable (aka. critical) findings documented in text or as coded entries, are typically found in the 9.5 Findings. The actionable findings may be duplicated in the 9.6 Impression in either text or as coded entries. The actionable findings may be new (critical) or a change to a previous report/diagnosis (discrepant).

Classification

CDA Section and Entry Level

Relationships

Included in 9.6 Impression and 9.7 Addendum

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

Actionable​Findings

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.11

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(73568-8, LOINC, "Communication of Critical Results")

Title

>

title

1..1

SHALL

ST

>

text

1..1

SHALL

ED

Content[*]

>>

content

0..*

SHALL

ST

[See 9.8.10.1 section/text/content - narrative]

*

>>@

@ID

1..1

SHALL

XML ID

Finding​Ref

>>>

link​Html

0..*

MAY

ST

Finding​URI

>>>@

@href

1..1

SHALL

URL (XML IDREF)

#findingRef

>

entry

0..*

SHOULD

Communication[*]

>>

act

1..1

SHALL

SHALL

>>@

@classCode

1..1

SHALL

CS

SHALL

ACT

>>@

@moodCode

1..1

SHALL

CS

SHALL

EVN

*

>>@

@ID

1..1

SHALL

XML ID

>>>

code

1..1

SHALL

CD

SHALL

(121291, DCM, "Results communicated")

Comm​Time

>>>

effective​Time

1..1

SHALL

TS

>>>

text

1..1

SHALL

ED

Ref

>>>>

reference

1..1

SHALL

URL (XML IDREF)

# content​Ref

>>>

performer

1..1

SHALL

>>>>

assigned​Entity

1..1

SHALL

>>>>>

assignedPerson

1..1

SHALL

Reporting​Physician​Name

>>>>>>

name

1..1

SHALL

PN

>>>

participant

1..1

SHALL

>>>@

@typeCode

1..1

SHALL

CS

SHALL

NOT

>>>>

participant​Role

1..1

SHALL

Notification​Contact​Telecom

>>>>>

telecom

1..1

SHALL

TEL

>>>>>

playing​Entity

1..1

SHALL

Notification​Contact​Name

>>>>>>

name

1..1

SHALL

PN

9.8.10.1 section/text/content - narrative

Each documented act of communication of actionable findings SHALL be included as narrative in a section/text/content element, labeled with an XML ID (see Section 9.1.1.1).

Note

The following text content for such a block is specified in the RSNA Radiology Reporting Templates, Template 297: Communication of Actionable Finding (http://radreport.org/txt-mrrt/0000297):

method [discussed directly | discussed by telephone | described in message]

by [person]

to [person]

on [<date>] at [<time>]

The documentation may also provide a linkHtml reference to the actionable finding narrative elsewhere in the report, e.g., in the 9.5 Findings or 9.8.4 Complications section (see Section 9.1.1.2).

Example 9.8.10-1. Communication of Actionable Results section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="1.2.840.10008.9.11"/>
    <id root="1.2.840.10213.2.62.7044794679.114296787"/>
    <code code="73568-8"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Communication of Critical Results"/>
    <title>Communication of Actionable Results</title>
    <text>
        <content ID=CR1>Dr. Smith was phoned at 262-966-0120 at 3:14pm on
        Wednesday, June 4, 2014, and the 4mm lung nodule was discussed directly
        with Dr. Smith to explain the follow-up recommendation of ...</content>
    </text>
    <entry>
        <act classCode="ACT" moodCode="EVN">
            <code code="121291"
                codeSystem="1.2.840.10008.2.16.4"
                codeSystemName="DCM"
                displayName="Results Communicated"/>
            <text>
                <reference value="#CR1"/>
            </text>
            <effectiveTime value="20140604221400-0700"/>
            <performer>
                <assignedEntity>
                    <id root="1.2.840.10213.2.62.7044794679.114298686"/>
                    <assignedPerson>
                        <name>Jane Doctor</name>
                    </assignedPerson>
                </assignedEntity>
            </performer>
            <participant typeCode="NOT">
                <participantRole>
                    <telecom value="tel:262-966-0120"/>
                    <playingEntity>
                        <name>Dr. Smith</name>
                    </playingEntity>
                </participantRole>
            </participant>
        </act>
    </entry>
</section>

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