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

9.8.8 Fetus Findings

Template ID

1.2.840.10008.9.9

Name

Fetus Findings

Effective Date

2015/03/24

Version Label

DICOM-20150324

Status

Active

Description

Records observations related to a fetus confirmed or discovered during an imaging procedure.

Classification

CDA Section Level

Relationships

Included in 9.5 Findings

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

Fetus​Findings[*]

section

1..1

SHALL

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

1.2.840.10008.9.9

>

id

1..*

SHALL

II

>

code

1..1

SHALL

CD

SHALL

(76514-9, LOINC, "Fetal Study observation")

Title

>

title

1..1

SHALL

ST

Text

>

text

1..1

COND

ED

9.1.1 Section Text 1.2.840.10008.9.19

>

subject

1..1

SHALL

>>

related​Subject

1..1

SHALL

>>>

code

1..1

SHALL

CE

SHALL

(121026, DCM, "Fetus")

>>>

subject

1..1

SHALL

Fetus​ID

>>>>

name

1..1

SHALL

PN

>

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

For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget/PatientRole/Patient in the CDA header. Information on the fetus is mapped to subject/relatedSubject/SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.

9.8.8.1 name - FetusID

The subject/relatedSubject/subject/name element is used to store the fetus ID, typically a pseudonym such as "fetus A". This shall be present even if only one fetus is identified in the document.

Example 9.8.8-1. Fetus Findings section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.27" />
    <id root="1.2.840.10213.2.62.70447834679.11429737"/>
    <code code="76514-9" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Fetal Study observation" />
    <title>Fetus #1</title>
    <text>Estimated gestational age of 27 weeks... </text>
    <relatedSubject>
        <code code="121026" codeSystem="1.2.840.10008.2.16.4" displayName="Fetus"/>
        <subject>
            <name>Fetus 1</name>
        </subject>
    </relatedSubject>
</section>

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