TID 2005 Transcribed Diagnostic Imaging Report

TID 2005 Transcribed Diagnostic Imaging Report (Current)
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Basic report Template for general diagnostic imaging interpretation reports produced in a dictation/transcription workflow. SR documents encoded using this Template are intended to be transformable to HL7 Clinical Document Architecture format (see Section X.3 “Transcribed Diagnostic Imaging CDA Instance Content” in PS3.17 and Annexes in PS3.20).

This Template can be instantiated only at the root node, and cannot be included in other Templates.

Observation Context shall be inherited from outside the Structured Report Content Tree, and shall not be changed within the Content Tree. To satisfy the requirement that Observer Context is inherited, either or both the Author Observer Sequence (0040,A078) or the Verifying Observer Sequence (0040,A073) from the SR Document General Module must be present in the SOP Instance.

Note

See Section C.17.5 “Observation Context Encoding” in PS3.3 .

Type:: Non-Extensible
Order:: Significant
Root:: Yes

Table TID 2005. Transcribed Diagnostic Imaging Report

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	BCID 7000 “Diagnostic Imaging Report Document Title”	1	M	Root node
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1-n	U
3	>	HAS CONCEPT MOD	CODE	EV (122142, DCM, "Acquisition Device Type")	1-n	U	DCID 29 “Acquisition Modality”
4	>	HAS CONCEPT MOD	CODE	EV (123014, DCM, "Target Region")	1-n	U
5	>	HAS CONCEPT MOD	CODE	EV (121049, DCM, "Language of Content Item and Descendants")	1	M	DCID 5000 “Language”
6	>	CONTAINS	CONTAINER	BCID 7001 “Diagnostic Imaging Report Heading”	1-n	M
7	>>	CONTAINS	TEXT	BCID 7002 “Diagnostic Imaging Report Element”	1	U
8	>	CONTAINS	CONTAINER	EV (55113-5, LN, "Key Images")	1-n	U
9	>>	CONTAINS	TEXT	EV (113012, DCM, "Key Object Description")	1	U
10	>>	CONTAINS	IMAGE		1-n	M

Content Item Descriptions

Rows 2, 3, 4	The content of Rows 2, 3, and 4 shall not be inconsistent with the meaning of the report title of Row 1. If the report title does not include the concepts of the procedure type, modality, or target site (e.g., the generic "Diagnostic Imaging Report"), these rows may provide post-coordination of those concepts. If the report title does include such concepts (e.g., "CT Head Report"), they may be encoded duplicatively to support report categorization and search.
Row 6	CONTAINER Concept Name may be absent.
Row 10	IMAGE Concept Name shall be absent. Purpose of reference is not specified.

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