TID 2006 Imaging Report With Conditional Radiation Exposure and Protection Information

TID 2006 Imaging Report With Conditional Radiation Exposure and Protection Information (Current)
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This Template is used for general imaging reports for both radiation producing and non-radiation producing modalities.

For radiation producing modalities, radiation exposure and protection information is required, such as to support nationally-specific legal or standard requirements.

It contains mandatory sections, each of which may appear only once in objects instantiated from the Template, including the medical content of the report that comprises relevant medical history data, information on the current request (i.e., clinical question that is expected to be answered by the requested procedure), impressions on the current imaging procedure that has been performed, and radiation exposure and protection information.

This Template is a specialization of TID 2000 “Basic Diagnostic Imaging Report”, in that it uses the same structure of headings and content, but mandates the presence and order of specific headings, and extends the subordinate content with specific Content Items.

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

Table TID 2006. Imaging Report With Conditional Radiation Exposure and Protection Information

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	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	INCLUDE	DTID 1204 “Language of Content Item and Descendants”	1	M
4	>	HAS CONCEPT MOD	INCLUDE	DTID 1210 “Equivalent Meaning(s) of Concept Name”	1-n	U
5	>	HAS OBS CONTEXT	INCLUDE	DTID 1001 “Observation Context”	1	M
6	>	CONTAINS	CONTAINER	EV (55111-9, LN, "Current Procedure Descriptions")	1	M
7	>>		INCLUDE	DTID 2007 “Imaging Procedure Description”	1	M
8	>	CONTAINS	CONTAINER	EV (55114-3, LN, "Prior Procedure Descriptions")	1-n	MC	IF relevant prior procedures have been performed.
9	>>		INCLUDE	DTID 2007 “Imaging Procedure Description”	1	M
10	>	CONTAINS	CONTAINER	EV (11329-0, LN, "History")	1	M
11	>>	HAS OBS CONTEXT	INCLUDE	DTID 1001 “Observation Context”	1	U
12	>>		INCLUDE	DTID 2002 “Report Narrative”	1	M
13	>	CONTAINS	CONTAINER	EV (55115-0, LN, "Request")	1	M
14	>>	HAS OBS CONTEXT	INCLUDE	DTID 1001 “Observation Context”	1	U
15	>>		INCLUDE	DTID 2002 “Report Narrative”	1	M
16	>	CONTAINS	CONTAINER	EV (19005-8, LN, "Impressions")	1	M
17	>>	HAS OBS CONTEXT	INCLUDE	DTID 1001 “Observation Context”	1	U
18	>>		INCLUDE	DTID 2002 “Report Narrative”	1	M
19	>	CONTAINS	INCLUDE	DTID 2008 “Radiation Exposure and Protection Information”	1	MC	IF the current procedure exposes the patient to ionizing radiation.
20	>	CONTAINS	CONTAINER	BCID 7001 “Diagnostic Imaging Report Heading”	1-n	U
21	>>	HAS OBS CONTEXT	INCLUDE	DTID 1001 “Observation Context”	1	U
22	>>		INCLUDE	DTID 2002 “Report Narrative”	1	M

No Content Items other than those defined in TID 1001 “Observation Context” may be the target of a HAS OBS CONTEXT relationship when TID 2006 “Imaging Report With Conditional Radiation Exposure and Protection Information” is invoked.

Content Item Descriptions

Row 2

Even though this information is related to the content of Row 6 in TID 2007 “Imaging Procedure Description”, it is present here for consistency with other report Templates.

Rows 5, 6

Information on at least one of the following person observers is mandatory:

1) "Performing Physician"

2) "Performing Technologist".

(For those person observers, requirement types as specified in TID 1003 “Person Observer Identifying Attributes” apply. That means that "Person Observer Name" is the only mandatory Content Item).

Row 20

Each heading (concept code from CID 7001 “Diagnostic Imaging Report Heading”) may appear only once, and may not repeat the headings (concept codes) used when instantiating any other rows of this Template.

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