DICOM PS3.17 2024e - Explanatory Information
X.3 Transcribed Diagnostic Imaging CDA Instance Content (Current)
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PS3.17 > Dictation-based Reporting With Image References (Informative) > Transcribed Diagnostic Imaging CDA Instance Content

X.3 Transcribed Diagnostic Imaging CDA Instance Content

This section describes the use of transcribed dictation and Key Object Selection (KO) documents to produce an HL7 Clinical Document Architecture (CDA) Release 2 document.

Note

While this section describes encoding as CDA Release 2, notes are provided about encoding issues for CDA Release 1.

X.3.1 CDA Header Content

The header of the CDA instance includes:

  • Identity of the patient ("recordTarget" participation)

  • Identity of the requested procedure ("documentationOf" act relationship)

  • Identity of the dictating physician ("author" participation)

  • Identity of the transcriptionist ("dataEnterer" participation)

  • Identity of the report signing physician ("legalAuthenticator" participation)

  • Identity of the institution owning the report ("custodian" participation)

  • Identity of the request/order ("inFulfillmentOf" act relationship)

Note

The markup components in CDA Release 1 use different names.

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DICOM PS3.17 2024e - Explanatory Information