| DICOM PS3.20 2024e - Imaging Reports using HL7 Clinical Document Architecture |
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This section provides a separate section to describe the study interpreter's recommendations for follow-up studies or procedures. |
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Included in 9.6 Impression |
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[See 9.8.11.1 text/content] |
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Each documented recommendation SHALL be included as narrative in a content element, labeled with an XML ID (see Section 9.1.1.1 <content> Markup and Links From Entries). The content element NEED NOT be top level markup within the section/text element; it MAY be wrapped in another allowed narrative block markup, such as paragraph, list/item, or table/row/cell.
If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element.
Each recommendation SHOULD have a corresponding structured entry.
Example 9.8.11-1. Radiology recommendation section example
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="1.2.840.10008.9.12" />
<id root="1.2.840.10213.2.62.7044779.114265201"/>
<code code="18783-1" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Study Recommendation"/>
<title>Radiology Recommendation</title>
<text>
<content ID="rec01">Biopsy should be considered. Follow-up at 3 month interval.
</content>
<linkHtml href="http://pubs.rsna.org/doi/abs/10.1148/radiol.2372041887"/>
</text>
<entry>
<procedure ID="RadRec1" classCode="PROC" moodCode="PRP"/>
<!-- local coding scheme -->
<code code="9191919" codeSystem="2.16.840.1.56789.6.1"
codeSystemName="My Hospital Coding System"
displayName="3 month follow-up"/>
<text><reference value="#rec01"/></text>
<effectiveTime value="20141213"/>
</entry>
</section>
| DICOM PS3.20 2024e - Imaging Reports using HL7 Clinical Document Architecture |
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