9.5 Findings

9.5 Findings (Current)
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Template ID	2.16.840.1.113883.10.20.6.1.2
Name	Findings
Effective Date	2015/03/24
Version Label	DICOM-20150324
Status	Active
Description	Records clinically significant observations confirmed or discovered during the procedure.
Classification	CDA Section Level
Relationships	Included in 7.1 Imaging Report
Context	parent node
Open/Closed	Open
Revision History	From Consolidated CDA r1.1 DICOM-20150324: Added optional subsections and entries

Business Name	Nest Level	Element/Attribute	Card	Elem/Attr Conf	Data Type	Value Conf	Value	Subsidiary Template
Findings		section
	>	templateId	1..1	SHALL	II
	>@	@root	1..1	SHALL	UID	SHALL	2.16.840.1.113883.10.20.6.1.2
	>	id	1..*	SHALL	II
	>	code	1..1	SHALL	CD	SHALL	(59776-5, LOINC, "Procedure Findings")
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..*	MAY
FetusFindings[*]	>>	section	1..1	SHALL				9.8.8 Fetus Findings 1.2.840.10008.9.9
	>	component	0..*	MAY
Subsection[*]	>>	section	1..1	SHALL				9.8.9 Labeled Subsection 1.2.840.10008.9.10
	>		0..1	MAY				9.1.2 General Section Entries 1.2.840.10008.9.23

9.5.1 text

If entries are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text.

The narrative text associated with an actionable finding SHOULD be highlighted using styleCode Bold. See Section 9.1.1.1.

Actionable findings that require a specific follow-up action or procedure SHOULD be referenced from a recommendation in the 9.8.11 Recommendation section.

Communication of actionable findings SHOULD be documented in the 9.8.10 Communication of Actionable Findings section.

Example 9.5.1-1. Findings section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.6.1.2"/>
    <id root="1.2.840.10213.2.62.941494044785528.114289542452452805"/>
    <code code="59776-5" codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" displayName="Procedure Findings"/>
    <title>Findings</title>
    <text>
        <paragraph>
            <caption>Finding</caption>
            <content ID="Fndng2">The cardiomediastinum is... </content>
        </paragraph>
        <paragraph>
            <caption>Diameter</caption>
            <content ID="Diam2">45mm</content>
        </paragraph>
        ...
    </text>
    <entry>
        <templateId root="2.16.840.1.113883.10.20.6.2.12"/>
        ...
    </entry>
    <!-- see examples for other sections/entries -->
</section>

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