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

9.8.2 Procedure Indications

Template ID

2.16.840.1.113883.​10.20.22.2.29

Name

Procedure Indications

Effective Date

2012-07

Version Label

DICOM-20150324

Status

Active

Description

Records details about the reason for the procedure. This section may include the pre-procedure diagnosis or diagnoses as well as one or more symptoms that contribute to the reason the procedure is being performed.

Classification

CDA Section Level

Relationships

Included in 9.2 Clinical Information

Context

parent node

Open/Closed

Open

Revision History

From Consolidated CDA r1.1

DICOM-20150324: adapted to use optional Coded Observation entry rather than optional Indication entry

Business Name

Nest Level

Element/​Attribute

Card

Elem/Attr Conf

Data Type

Value Conf

Value

Subsidiary Template

Procedure​Indications

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

2.16.840.1.113883.​10.20.22.2.29

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(59768-2, LOINC, "Procedure Indications")

Title

>

title

1..1

SHALL

ST

Text

>

text

1..1

COND

ED

9.1.1 Section Text 1.2.840.10008.9.19

>

entry

0..*

MAY

Coded​Observation[*]

>>

observation

1..1

SHALL

See 9.8.2.1 entry/observation

10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

9.8.2.1 entry/observation

The binding to the Coded Observation concept domains is:

Concept Domain or Element

Value Conf

Value

Observation​Type

SHOULD

(432678004, SNOMED, "Indication for procedure")

Other concept domains

unspecified

Note

In Consolidated CDA r1.1 the binding to the observationType is to Value Set Problem Type (2.16.840.1.113883.3.88.12.3221.7.2) with conformance SHOULD. Values from that Value Set are acceptable here as well.

Example 9.8.2.1-1. Procedure indications section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.29"/>
    <id root="1.2.840.10213.2.62.044785528.1142895426"/>
    <code code="59768-2"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Procedure Indications"/>
    <title>Procedure Indications</title>
    <text>The procedure is performed as a follow-up for abnormal screening result.</text>
</section>

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