9.2 Clinical Information

9.2 Clinical Information (Current)
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Template ID	1.2.840.10008.9.2
Name	Clinical Information
Effective Date	2015/03/24
Version Label	DICOM-20150324
Status	Active
Description	Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc.
Classification	CDA Section Level
Relationships	Included in 7.1 Imaging Report
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
ClinicalInformation		section	1..1	SHALL
	>	templateId	1..1	SHALL	II
	>@	@root	1..1	SHALL	UID	SHALL	1.2.840.10008.9.2
	>	id	1..1	SHALL	II
	>	code	1..1	SHALL	CD	SHALL	(55752-0, LOINC, "Clinical Information")
Title	>	title	1..1	SHALL	ST
Text	>	text	1..1	COND	ED			9.1.1 Section Text 1.2.840.10008.9.19
	>	component	0..1	MAY
Request	>>	section	1..1	SHALL				9.8.1 Request 1.2.840.10008.9.7
	>	component	0..1	MAY
ProcedureIndications	>>	section	1..1	SHALL				9.8.2 Procedure Indications 1.2.840.10008.9.22
	>	component	0..1	MAY
History	>>	section	1..1	SHALL				9.8.3 Medical (General) History 2.16.840.1.113883.10.20.22.2.39
	>		0..1	MAY				9.1.2 General Section Entries 1.2.840.10008.9.23

Example 9.2-1. Clinical Information section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="1.2.840.10008.9.2"/>
    <id root="1.2.840.10213.2.62.994044785528.114289542805"/>
    <code code="55752-0" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Clinical Information"/>
    <title>Clinical Information</title>
    <text>The patient was referred for evaluation of suspected pulmonary embolism.</text>
    <!---see examples for other sections/entries -->
</section>