7 Document-level Templates (Current)
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7 Document-level Templates

Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and sections by referring to templates, and constraints on the vocabulary used in those templates.

7.1 Imaging Report

Template ID	1.2.840.10008.9.1
Name	Imaging Report
Effective Date	2015/03/24
Version Label	DICOM-20150324
Status	Active
Description	This CDA Imaging Report document template defines the report content and technical constraints for top level elements, attributes, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or therapeutic radiology, cardiology, or other imaging reports. The body of an Imaging Report may contain five main imaging report sections: Clinical information (optionally); Current imaging procedure description; Comparison studies (optionally); Findings (optionally); Impression; plus potentially an Addendum(s) The report templates sponsored by the RSNA Radiology Reporting Initiative (http://www.radreport.org) adhere to this general section outline. The section and subsection structure of this template is also identified by LOINC panel code 87416-4.
Classification	CDA Document Level
Relationships
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
ImagingReport		ClinicalDocument
	>	templateId	1..1	SHALL	II
	>@	@root	1..1	SHALL	UID	SHALL	1.2.840.10008.9.1
DocType	>	code	1..1	SHALL	CD	SHALL CWE noNull	ValueSet LOINC Imaging Document Codes 1.3.6.1.4.1.12009.10.2.5
	>		1..1	SHALL				8.1 General Header 1.2.840.10008.9.20
	>		1..1	SHALL				8.2 Imaging Header 1.2.840.10008.9.21
	>		0..1	MAY				8.3 Parent Document 1.2.840.10008.9.22
	>	component	1..1	SHALL
	>>	structuredBody	1..1	SHALL
	>>>	component	0..1	MAY
ClinicalInformation	>>>>	section						9.2 Clinical Information 1.2.840.10008.9.2
	>>>	component	1..1	SHALL
ProcedureDescription	>>>>	section						9.3 Imaging Procedure Description 1.2.840.10008.9.3
	>>>	component	0..1	MAY
ComparisonStudy	>>>>	section						9.4 Comparison Study 1.2.840.10008.9.4
	>>>	component	0..1	MAY
Findings	>>>>	section						9.5 Findings 2.16.840.1.113883.10.20.6.1.2
	>>>	component	1..1	SHALL
Impression	>>>>	section						9.6 Impression 1.2.840.10008.9.5
	>>>	component	0..*	COND
Addendum[*]	>>>>	section						9.7 Addendum 1.2.840.10008.9.6

7.1.1 clinicalDocument/code

Most of the codes in Value Set LOINC Imaging Document Codes are pre-coordinated with the imaging modality, body part examined, and/or specific imaging method. When pre-coordinated codes are used, any coded values elsewhere in the document describing the modality, body part, etc., must be consistent with the document type code. Local codes used for report types may be included as a translation element in the code.

Note

Use of Value Set LOINC Imaging Document Codes is harmonized with HL7 Consolidated CDA Templates for Clinical Notes, Release 2. DICOM CID 7001 “Diagnostic Imaging Report Heading”, used in TID 2000 “Basic Diagnostic Imaging Report”, is a subset of the LOINC Imaging Document Codes.

Example 7.1.1-1. clinicalDocument/code example with translation element for local code

<code code="18748-4"
        displayName="Diagnostic Imaging Report"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" >
    <translation code="XRPEDS"
        displayName="Pediatric Radiography Report"
        codeSystem="2.16.840.1.123456.78.9" />
</code>

7.1.2 Addendum

COND: If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator element (i.e., was signed), the component/structuredBody SHALL contain at least one 9.7 Addendum.

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6 Conformance	Home	7.2 Imaging Addendum Report