| DICOM PS3.20 2024d - Imaging Reports using HL7 Clinical Document Architecture |
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Each template is specified in tabular form, as shown in Table 5.2-1.
This Part uses Business Names to identify and map common data elements from clinical imaging reports into the proper context-specific CDA/XML structure.
A Business Name is assigned to each element or attribute that may have a user-specified value assigned in the production of the clinical document instance. Business Names are specified to facilitate the implementation of production logic for clinical report authoring applications. The benefit is that developers of clinical report authoring applications are not required to have an in depth knowledge of CDA, the HL7 v3 R-MIM data model, or the XML structures. The use of readable and intuitive Business Names provides a method of direct access to insert data that is specific to each clinical report instance.
Business Names are also described in the HL7 greenCDAModules for CCD specification, but that specification implies the use of a specific XML structure for production logic that is not required by this Part. The specification of production logic using Business Names is outside the scope of this Part.
Business Names are not specified for elements that are expected to receive an automatically generated value, e.g., the id element for each document, section, and entry.
As a convention, Business Names are represented in CamelCase (alternating upper and lower case, no spaces, initial letter in upper case) in the Business Name column of the template tables.
Business Names are hierarchically organized, and contextually scoped by higher level Business Names.
Data element/attribute level Business Names are shown in normal font
Business Names that provide scoping for subsidiary Business Names are shown in bold font.
Referenced Business Names from included templates are shown in italic (see Section 5.2.9)
As a convention, hierarchical relationship between Business Names is shown with the : character.
Scoping Business Names scope all attributes and elements subsidiary to the element to which the name is assigned.
The top level scoping Business Name for an Imaging Report is "ImagingReport", and it scopes all attributes and elements in the document, i.e., including and subsidiary to the <ClinicalDocument> XML element
The Business Name for the 9.2 Clinical Information report section is "ImagingReport:ClinicalInformation", and it scopes all attributes and elements including and subsidiary to the <section> XML element in template 1.2.840.10008.9.2
The Business Name for the text element of the 9.2 Clinical Information report section is "ImagingReport:ClinicalInformation:Text"
The Business Name for the text element of the 9.6 Impression section is "ImagingReport:Impression:Text"
Note that both 9.2 Clinical Information and 9.6 Impression define a Business Name "Text", but these are distinguished by their hierarchical location under the scoping Business Names of their respective sections.
Some templates or elements may be invoked multiple times in a document instance; for example, the 10.5 Quantity Measurement template is instantiated for each numeric measurement in a report. Each instantiation may have an identifying string, unique within the document, used as a discriminator between those multiple instantiations. The Business Name for each element that may have multiple instantiations has a suffix [*], indicating the use of a discriminator string. This allows Business Name based production logic for authoring applications to identify specific instances of an element.
Production logic based on Business Names should allow single instantiations of elements without a discriminator; for instance, Section 8.1 General Header specifies Patient[*], allowing multiple patients to be recorded in special cases, although the vast majority of reports will be for a single patient for which a discriminator is unnecessary.
Example 5.2.1.1-1. Example Business Name based production logic with discriminators for two measurements
-- "Q21a" is the discriminator for the first measurement
-- "Q21b" is the discriminator for the second measurement
ImagingReport:Findings:QuantityMeasurement[Q21a]:MeasurementName = ("112058", "DCM", "Calcium score")
ImagingReport:Findings:QuantityMeasurement[Q21a]:MeasurementValue = "8"
ImagingReport:Findings:QuantityMeasurement[Q21a]:MeasurementUnits = "[arb'U]"
ImagingReport:Findings:QuantityMeasurement[Q21b]:MeasurementName = ("408716009", "SNOMED", "Stenotic lesion length")
ImagingReport:Findings:QuantityMeasurement[Q21b]:MeasurementValue = "14"
ImagingReport:Findings:QuantityMeasurement[Q21b]:MeasurementUnits = "mm"
The discriminator string shall be conformant to XML Name production requirements, as used for the XML ID attribute (see Section 5.3.4 on the use of XML ID).
Some CDA elements may include an XML ID attribute. This attribute is identified by '*' (asterisk) as its Business Name, and its value shall be the discriminator string.
A Business Name may be associated with an element subsidiary to another element that does not have an associated Business Name. In such a case, when the element with the Business Name is instantiated in a document, its entire parent element hierarchy must be instantiated, even if those elements are identified as optional.
For example, in the 8.1 General Header template, if Recipient:Name is instantiated, the entire hierarchical structure of informationRecipient/intendedRecipient/informationRecipient/name must be instantiated to hold the name element content.
| DICOM PS3.20 2024d - Imaging Reports using HL7 Clinical Document Architecture |
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