| DICOM PS3.20 2025a - Imaging Reports using HL7 Clinical Document Architecture |
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A section that documents the notification of an actionable finding to a provider or other person responsible for patient care. The documentation in narrative text, and optionally in a coded entry, includes by whom, to whom, and at what date/time. Specific findings, including actionable (aka. critical) findings documented in text or as coded entries, are typically found in the 9.5 Findings. The actionable findings may be duplicated in the 9.6 Impression in either text or as coded entries. The actionable findings may be new (critical) or a change to a previous report/diagnosis (discrepant). |
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Included in 9.6 Impression and 9.7 Addendum |
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Each documented act of communication of actionable findings SHALL be included as narrative in a section/text/content element, labeled with an XML ID (see Section 9.1.1.1).
The following text content for such a block is specified in the RSNA Radiology Reporting Templates, Template 297: Communication of Actionable Finding (http://radreport.org/txt-mrrt/0000297):
method [discussed directly | discussed by telephone | described in message]
The documentation may also provide a linkHtml reference to the actionable finding narrative elsewhere in the report, e.g., in the 9.5 Findings or 9.8.4 Complications section (see Section 9.1.1.2).
Example 9.8.10-1. Communication of Actionable Results section example
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="1.2.840.10008.9.11"/>
<id root="1.2.840.10213.2.62.7044794679.114296787"/>
<code code="73568-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Communication of Critical Results"/>
<title>Communication of Actionable Results</title>
<text>
<content ID=CR1>Dr. Smith was phoned at 262-966-0120 at 3:14pm on
Wednesday, June 4, 2014, and the 4mm lung nodule was discussed directly
with Dr. Smith to explain the follow-up recommendation of ...</content>
</text>
<entry>
<act classCode="ACT" moodCode="EVN">
<code code="121291"
codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM"
displayName="Results Communicated"/>
<text>
<reference value="#CR1"/>
</text>
<effectiveTime value="20140604221400-0700"/>
<performer>
<assignedEntity>
<id root="1.2.840.10213.2.62.7044794679.114298686"/>
<assignedPerson>
<name>Jane Doctor</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="NOT">
<participantRole>
<telecom value="tel:262-966-0120"/>
<playingEntity>
<name>Dr. Smith</name>
</playingEntity>
</participantRole>
</participant>
</act>
</entry>
</section>
| DICOM PS3.20 2025a - Imaging Reports using HL7 Clinical Document Architecture |
|---|