The N-CREATE procedures are initiated by the Invoking DIMSE Service User issuing an N-CREATE Request primitive. On receipt of the N-CREATE Request primitive the DIMSE-N protocol machine shall:

On receipt of a Message conveying an N-CREATE-RQ the DIMSE-N protocol machine shall issue an N-CREATE indication primitive to the Performing DIMSE Service User.

On receipt of the N-CREATE response primitive, issued by the Performing DIMSE Service User, the DIMSE-N protocol machine shall:

On receipt of a Message conveying an N-CREATE-RSP the DIMSE-N protocol machine shall issue an N-CREATE confirmation primitive to the Invoking DIMSE Service User, thus completing the N-CREATE procedure.

The Performing DIMSE Service User may return an N-CREATE-RSP with the status of Failed or Refused before the complete N-CREATE-RQ request Message has been completely transmitted by the Invoking DIMSE Service User (this is called an early failed response). Upon receipt of this Failed or Refused N-CREATE-RSP the Invoking DIMSE Service User may terminate the Message before it is completely sent (i.e., set the Last Fragment bit to 1 in a Data PDV for this Message, see Annex F). Following this, it may invoke another operation or notification. It is a protocol violation for an Invoking DIMSE Service User to set the Last Fragment bit to 1 before an N-CREATE-RQ Message has been completely transmitted if it has not received a Failed or Refused N-CREATE-RSP to that request.