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

9.8.4 Complications

Template ID

2.16.840.1.113883.​10.20.22.2.37

Name

Complications

Effective Date

2012-07

Version Label

DICOM-20150324

Status

Active

Description

The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.

Classification

CDA Section Level

Relationships

Included in 9.3 Imaging Procedure Description

Context

parent node

Open/Closed

Open

Revision History

From Consolidated CDA r1.1

DICOM-20150324: Addition of optional entries

Business Name

Nest Level

Element/​Attribute

Card

Elem/Attr Conf

Data Type

Value Conf

Value

Subsidiary Template

Complications

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

2.16.840.1.113883.​10.20.22.2.37

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(55109-3, LOINC, "Complications")

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

10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

Example 9.8.4-1. Complications section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.37"/>
    <id root="1.2.840.10213.2.62.70444786655528.11428987524546666"/>
    <code code="55109-3"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Complications"/>
    <title>Complications</title>
    <text>Immediately following IV contrast injection, the patient reporting itching "all over".
        Dr. Smith examined the patient and found multiple urticaria. The patient denied difficulty
        breathing or swallowing. The patient was given Benadryl 50 mg PO and was followed for
        30 minutes, during which time the symptoms subsided.</text>
    <entry>
        <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.6.2.13"/>
            <!-- Coded Observation -->
            ...
        </observation>
    </entry>
</section>

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