Zavěšení motoru GSP 517739 - 517739

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Note that inclusion in a labeled subsection (see SectionÂ 9.8.9) does not imply a finding site for the observation from the title. The title is not semantically part of the post-coordination.

Participant Sequence (0040,A07A) Person Name (0040,A123) [where Participation Type (0040,A080) equals "ENT" (Data Enterer) ]

Many data types are non-primitive, and may include constituent component elements and/or attributes. Such subsidiary components are not specified in the templates unless specific constraints are to be applied to them.

Each documented recommendation SHALL be included as narrative in a content element, labeled with an XML ID (see SectionÂ 9.1.1.1 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.

This Part follows the convention used in the Consolidated CDA Implementation Guide specification, which specifies the standard interoperable code in the root, whether it is original or a translation. The HL7v3 Data Types R1 standard included by CDA formally specifies the original code (as initially entered in an information system application) to be placed in the root.

NEMA standards and guideline publications, of which the document contained herein is one, are developed through a voluntary consensus standards development process. This process brings together volunteers and/or seeks out the views of persons who have an interest in the topic covered by this publication. While NEMA administers the process and establishes rules to promote fairness in the development of consensus, it does not write the document and it does not independently test, evaluate, or verify the accuracy or completeness of any information or the soundness of any judgments contained in its standards and guideline publications.

In Consolidated CDA r1.1 the binding to the observationType is to Value Set Problem Type (2.16.840.1.113883.3.88.12.3221.7.2) with conformance SHOULD. Values from that Value Set are acceptable here as well.

This Annex provided a transformation of SR documents based on TID 2000 Basic Diagnostic Imaging Report to HL7 CDA Release 2 Imaging Reports based on the HL7 Diagnostic Imaging Reports (DIR) Release 1.0 Informative specification Template 2.16.840.1.113883.10.20.6.

The above null flavors are commonly used in clinical documents. For the full list and descriptions, see the nullFlavor vocabulary domain in the HL7 v3 Vocabulary referenced by the CDA specification.

The serviceEvent/code/translation elements include codes representing the primary image acquisition modality using DICOM (DCM) terminology, and target anatomic region (for which SNOMED terminology is recommended).

This CDA Imaging Report document template defines the report content and technical constraints for top level elements, attributes, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or therapeutic radiology, cardiology, or other imaging reports.

The following term used in this Part of the DICOM Standard is defined in the HL7 Templates Standard, and applies to CDA template specifications:

The CDA narrative block MAY contain the markup to provide a link between narrative text in one section and a content block in another section (see CDA R2 specification section 4.3.5.2). The XML ID of the target content block is used in the linkHtml href attribute, with a prefixed '#' to indicate the reference is in the current document.

IHE ITI TF IHE IT Infrastructure Technical Framework, Revision 11.0, September 2014 (http://www.ihe.net/Technical_Frameworks/#IT)

This Part of the DICOM Standard specifies templates for the encoding of imaging reports using the HL7 Clinical Document Architecture Release 2 (CDA R2, or simply CDA) Standard. Within this scope are clinical procedure reports for specialties that use imaging for screening, diagnostic, or therapeutic purposes.

Information technology solutions store and manage data, but sometimes data are not available: an item may be unknown, not relevant, or not computable or measurable. In HL7 v3, a flavor of null, or nullFlavor, describes the reason for missing data.

The narrative text associated with the actionable finding SHOULD be highlighted using styleCode Bold. See SectionÂ 9.5.1 and SectionÂ 9.1.1.1.

Additionally, a content block may include a styleCode attribute to suggest rendering (see CDA R2 Specification, section 4.3.5.11). For example, Bold could also be used to highlight actionable findings in the text of the 9.5 Findings and/or 9.6 Impression sections.

The Key Images section MAY include observationMedia entries with in-line encoded copies of the referenced images, linked into the narrative block using the renderMultiMedia markup. See SectionÂ 9.1.1.3. These in-line encoded images may have limited resolution and lossy compression as appropriate for inclusion in a report.

The setID and versionNumber elements may be used by the document creation system to manage document revisions, in accordance with the CDA specification sections 4.2.1.7 and 4.2.1.8.

Procedural medication describes a substance administration that has actually occurred prior to or during a procedure (e.g., imaging contrast/agents, anti-histamines, anti-anxiety, beta blockers to control heart rate during procedure, etc.).

Information about the requested imaging studies and associated tests. It may include information on the reason for the request, and on any validation of the request by clinical decision support against relevant appropriateness criteria.

The keywords SHALL, SHOULD, MAY, SHOULD NOT, SHALL NOT, and NEED NOT in this document are to be interpreted as described in ISO/IEC Directives, Part 2, Annex H "Verbal forms for the expression of provisions":

Such author SHALL contain exactly one [1..1] time representing the start time of the author's participation in the creation of the content of the clinical document.

In the CDA R2 Specification, the XML ID attribute capability is applied to the Section and observationMedia elements, and to various types of narrative block markup, and is used to provide linkage between structured entries and the corresponding narrative text (see SectionÂ 9.1.1 Section Text).

XML Extensible Markup Language (XML) 1.0 (Fifth Edition), World Wide Web Consortium, 2008 (http://www.w3.org/TR/REC-xml/)

The name of each XML element and attribute used in a CDA document for which specific constraints are applied is shown in the Element/Attribute column of the template tables. Optional elements whose use is not specified nor constrained are not shown.

If the creator doesn't know if an act occurred, the nullFlavor is on the act (detail could include specific allergy, drug, etc.).

A template may be further qualified by a version label. This label may be used as the extension attribute of the templateID (e.g., @extension="20150309"). All versions of a template, regardless of the version label, must be compatible; i.e., they may vary only by optional content conformance requirements. Thus the version label is typically not used as a conformance constraint.

The XML Specification allows a markup tag to have an attribute of type ID, whose value is unique within the document, that allows reference to that markup. The CDA schema defines such attributes with attribute name ID.

The procedure entry SHALL include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative content block. See SectionÂ 9.1.1.1.

The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, Visit Number, or Admission ID, equivalent to DICOM attribute (0038,0010), that number should be present as the ID of the encompassingEncounter.

The mechanism of identifying specific codes to be used to express the semantics of coded model elements in information models or coded data type properties. Vocabulary Binding may bind the coded element or data type property to a single fixed value code, or may bind it to a Value Set Assertion.

For transformation of the body, this Section maps the SR content items to their target CDA elements. This allows the transforming application to traverse the SR content tree and construct equivalent CDA content.

It is possible for an imaging report to be legally signed (authenticated) prior to the Actionable Findings being properly communicated. In this event, an addendum to the imaging report is often created to document the communication of the actionable findings. This can be included in the section/text of the 9.7 Addendum, or using the 9.8.10 Communication of Actionable Findings subsection.

The narrative rendered from each Content Item shall be encapsulated in a element of the narrative block, allowing the associated entry to reference it.

the name of the "Irradiation Authorizing" person who is the clinician responsible for determining that the irradiating procedure was appropriate for the indications.

NEMA has no power, nor does it undertake to police or enforce compliance with the contents of this document. NEMA does not certify, test, or inspect products, designs, or installations for safety or health purposes. Any certification or other statement of compliance with any health or safety-related information in this document shall not be attributable to NEMA and is solely the responsibility of the certifier or maker of the statement.

COND: The XML ID attribute SHALL be present for a table or a table row if the content is referenced from elsewhere in the document.

Each documentationOf/serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the report. The main activity being described by this document is both the performance of the imaging procedure and the interpretation of the imaging procedure.

ANSI/HL7 V3 DT, R1-2004 HL7 Version 3 Data Types Abstract Specification, Release 1 - November 2004. [Note: this specific release version is required by CDA R2]

COND: If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator element (i.e., was signed), the component/structuredBody SHALL contain at least one 9.7 Addendum.

A uniquely identifiable set of valid concept identifiers. Value sets constrain the permissible content for a coded element in an information model or data type specification.

Elements whose value may be mapped from a DICOM SOP Instance or from an HL7v2 message have the source attribute name and tag identified in the Value column in italic font. Note that many of these values have their origin in IT systems outside the imaging department, and there may be alternate routes for these values to be accessed by the reporting application, e.g., from an HL7 FHIR web service.

This template defines a primary scoping business name "ProceduralMedication" and an alias "Contrast". This allows production logic to use either term, although the structure is identical.

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.

3 reviews of ONE STOP PARTS SOURCE "We have these guys delivery quality parts to us a few times a day 6 days a week. Randy's all business.

Each Content Item immediately subsidiary to a section CONTAINER shall be mapped to the corresponding entry level template, and shall be included subsidiary to the associated CDA section or subsection. This is in addition to its rendering in the section/text narrative block.

The translation element of the interpretationCode may be used to provide a further classification as defined in a regionally- or professionally-specified value set. This template identifies an optional value set for the ACR Actionable Finding categories 1, 2, and 3, as defined by: Larson PA, et al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016.

An indication for procedure recorded in this section should be consistent with any indications identified in the 9.2 Clinical Information and/or 9.8.2 Procedure Indications section. It is included here for conformance with regulatory requirements in some jurisdictions for the indications to be specified in the context of the radiation exposure information.

For example, the various header templates are siblings, specifying sets of elements at the same hierarchical level. These elements of different templates must be encoded in their appropriate serialized order in the object instance - all templateID elements from the document template and all header templates first, followed by the elements of the clinicalDocument class in their prescribed order, followed by the participations in their prescribed order, followed by act relationships in their prescribed order.

The actual CDA schema specification uses the XML Schema Datatypes definition of XML ID (xs:ID). Readers may also be familiar with the xml:id specification, which is not formally used by CDA as it was published after the CDA specification.

This encounterParticipant with typeCode="ATND" (Attender) is the attending physician and is usually different from the Physician Reading Study Performer defined in documentationOf/serviceEvent.

The SR templates invoked for NUM measurements from TID 2000 do not specifically include finding site, laterality, and topographical modifiers, but these modifiers are not forbidden in the template, they are used in many other NUM value templates (e.g., TID 300 Measurement), and may be present in a SR SOP Instance being transformed to CDA.

Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet").

information on the radioactive substance administered if radioactive substance is administered in the context of the current procedure.

sdtc:signatureText - Provides a location for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of the element content are described in the HL7 CDA Digital Signature Standard. This extension uses the ED Data Type.

See Travis, A., et al., "Preferences for Structured Reporting of Measurement Data", JAcadRadiology 21:6 DOI:10.1016/j.acra.2014.02.008

The CDA narrative block MAY contain the markup to provide a link between narrative text and an external (non-attested) resource (see CDA R2 specification section 4.3.5.2).

Each element/attribute has a cardinality indicator that specifies the number of allowable occurrences within a template instance. The cardinality indicators are interpreted with the following format "mâ¦n" where m represents the least and n the most:

The CODE observations in TID 2002 do not specifically include finding site, laterality, and topographical modifiers, but these modifiers are not forbidden in the template, and may be present in a SR SOP Instance being transformed to CDA.

The namespace for extensions defined by HL7 is "urn:hl7-org:sdtc". which is aliased in this Standard as "sdtc". HL7 defined extensions used in this Standard are:

History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.

Thus the attribute named ID is of XML attribute type ID. This must further be distinguished from the element named id of HL7v3 Data Type UID that is part of most RIM classes. The attribute name is always upper case, the element name is always lower case.

DICOM-20150324: Added optional negationInd, interpretationCode, targetSiteCode, and methodCode with Business Names; added optional subject Coded Observation

Concept Domains (see definition in ) are used to provide a named category in a structural template that can be bound to a specific value or value set by an invoking template, thus specializing the structural template for a particular use case. Concept Domain names are introduced by the keyword ConceptDomain in the Value column. For example, the 10.5 Quantity Measurement template Concept Domain "observationType" might be bound to a value set of fetal ultrasound measurements in one invoking template, or to a value set of cardiac CT measurements in another invoking template.

The encoding of nullFlavor as an attribute of the data type element is not shown in the templates, hence there is no business name associated with the attribute.

The Radiation Exposure Content Item in TID 2008 uses Value Type TEXT, not NUM, and is therefore mapped to a Coded Observation entry in accordance with SectionÂ C.4.3.2.

Section templates defined in this Implementation guide SHALL NOT use the CDA Region of Interest Overlay entry (classCode="ROIOVL"). If it is desired to show images with graphical annotations, the annotations SHOULD be encoded in DICOM Presentation State objects that reference the image. Report applications that display referenced images and annotation may retrieve a rendered image using a WADO reference in accordance with PS3.18, including the image and Presentation State, or other DICOM retrieval and rendering methods. This approach avoids the risks of errors in registering a CDA region of interest annotation with DICOM images, and places all image rendering within the scope of the DICOM Standard, including the full range of 2D and 3D presentations defined in DICOM.

As an implementation guide for imaging reports, particular attention is given to the use and reference of data collected in imaging procedures as explicit evidence within reports. This data includes images, waveforms, measurements, annotations, and other analytic results managed as DICOM SOP Instances. Specifically, this Part includes a specification for transformation into CDA documents of DICOM Structured Report instances that represent imaging reports.

SR TID 2001 and TID 2002 allow Content Items to be INFERRED FROM IMAGE observations. The INFERRED FROM relationship is mapped to the entryRelationship with typeCode=SPRT, and the IMAGE observation is mapped to a CDA SOP Instance Observation entry subsidiary to its parent CDA Coded Observation or Quantity Measurement entry. This entryRelationship is shown in the Coded Observation and Quantity Measurement CDA Templates.

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).

The legalAuthenticator identifies the single person legally responsible for the correctness of the content of the document and SHALL be present if the document has been legally authenticated. In the context of an imaging report, this means the radiologist, cardiologist, or other professional who signed or validated the report.

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.

This template recursively invokes itself to allow a Presentation State SOP Instance reference to identify the target Image SOP Instances, or for a derived Image to reference its source Image, or similar linkages between instances.

XPath syntax selects nodes from an XML document using a path containing the context of the node(s). The path is constructed from node names and attribute names (prefixed by a '@') and concatenated with a '/' symbol.

Multiple recordTarget elements should be used only in the case of conjoined twins/triplets who are the subject of a single imaging procedure, or for special cases (e.g., pre-natal surgery, where a medical record has been established for the fetus).

Participant Sequence (0040,A07A) > Person Identification Code Sequence (0040,1101) , [where Participation Type (0040,A080) equals "ENT" (Data Enterer); code value as identifier]

COND: If this template is invoked by the 9.8.7 DICOM Object Catalog, the entryRelationship to the Series act SHALL be present, otherwise it MAY be present.

Spatial Coordinates: The mapping does not support SCOORD observations. As CDA documents are principally for human reading, detailed ROI data is presumed to reside in the DICOM SOP Instances of the study, or in images ready for rendering with a Presentation State, not in the CDA report. Template 1.2.840.10008.9.1 does not support the CDA Region of Interest Overlay entry class (see SectionÂ 9.1.2.4).

The title element is used to identify the topic (specific organ or anatomic feature, abnormality, lesion, etc.) as the subject of the sub-section findings in the human readable document. As there is no section.code, this is the required mechanism to represent the section purpose as free text.

The discriminator string shall be conformant to XML Name production requirements, as used for the XML ID attribute (see SectionÂ 5.3.4 on the use of XML ID).

The narrative block allows a variety of markup. The markup that implements various types of internal and external linkage is shown in the table, and is included in the conformance specifications for each section narrative block that invokes this template. The markup elements may occur in any order and at any point within the narrative block text as allowed by the CDA R2 specification.

DICOM TID 2002 Report Narrative specifies that sections contain imaging report elements of type CODE, TEXT, IMAGE, or NUM.

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

Each CONTAINER immediately subsidiary to the root CONTAINER shall be mapped to the section or subsection as specified in TableÂ C.4-1. Note that some SR document sections are mapped to subsections under CDA Template 1.2.840.10008.9.1.

Data mapped from an SR Content Item is identified by the Concept Name of the Content Item, represented in the mapping tables as a triplet in italic font:

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

As described in the HL7 Template specification section 2.9.9.4, the context identifies whether the template applies to the parent node in which the templateID is an element, or applies to its sibling nodes in the template table. These typically are applied respectively to templates with a single parent element with child element structure, and to templates with flat list of sibling elements (see SectionÂ 5.2.8).

A template may include subsidiary templates. Templates typically have one of two styles, a single parent element with child element structure, or a flat list of sibling elements.

The Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element of the Observation class) SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See SectionÂ 9.1.1.1.

Comfort Zone Fans - My Cooling Store - Comfort Zone is a leading brand of cooling fans. Comfort Zone Fans include personal fans, table fans, pedestal fans, ...

The CDA schema requires elements to be encoded in a specified order, which may be different than the order in which they are described in the templates. The serialization of elements shall be in accordance with the HL7 CDA Hierarchical Description. In particular, attention must be paid to the serialization order of elements defined in sibling templates (see SectionÂ 5.1.2).

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.

The section/code element shall be populated in accordance with the relevant CDA template; note that the code might not be the same as the Concept Name code of the SR section CONTAINER. The title element of each CDA section shall be populated as shown in TableÂ C.4-2.

The entry/act/effectiveTime element represents the date and time that actionable findings were communicated. The time that the findings were first observed is recorded in the effectiveTime element of the original observation, as linked through the section/text/content/linkHtml element.

Binding of the Concept Domains ProcedureCode and AnatomicRegion to specific Value Sets may be done in a further profiling of the use of this Template.

Coded concepts that are encoded in the SR using with the Coding Scheme Designator "SRT" shall be mapped to the equivalent SNOMED CT code. Mappings for value sets invoked in both SR and CDA are provided in PS3.16.

The DICOM SR Document General Module may specify the Reason for the Requested Procedure as either free text in attribute (0040,1002), and/or as multiple coded values in attribute (0040,100A). These are mapped to the Procedure Indications subsection of the Clinical Information section of the CDA Imaging Report.

Further, Value Set constraints can be static, meaning that they are bound to a specified version of a Value Set, or dynamic, meaning that they are bound to the most current version of the Value Set. By default, Value Sets have dynamic binding, unless explicitly specified with an additional constraint keyword static.

Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration.

Note that the Author identified in the document header is the author of the original report, as that participation sets the default authoring context for the report. The Author participation in this section shall be present, and identifies the author of the addendum, even if the same as the author of the original report.

The following standards contain provisions that, through reference in this text, constitute provisions of this Standard. At the time of publication, the editions indicated were valid. All standards are subject to revision, and parties to agreements based on this Standard are encouraged to investigate the possibilities of applying the most recent editions of the standards indicated below.

A source document from which the present document is transformed (typeCode = XFRM). A document may be created by transformation from a DICOM Structured Report (SR) document (see Annex C).

The informationRecipient participation elements record the intended recipients of the information at the time the document is created. An intended recipient may be a person (an informationRecipient entity), with or without an organization affiliation (receivedOrganization scoping entity), or simply an organization. If an organization, the document is expected to be incorporated into an information system of that organization (e.g., the electronic medical record for the patient).

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

XML element in template 1.2.840.10008.9.2

Subject Context: The mapping does not support the subject of any of the report sections to be a specimen TID 1009), a device (TID 1010), or a non-human subject. Only a fetus subject context is supported for a Findings section.

This template specifies a structure and Business Names for list markup in the narrative text, as described in the CDA Specification section 4.3.5.8. Inclusion of the listType="ordered" attribute specifies a numbered list of items.

This product includes all or a portion of the UCUM table, UCUM codes, and UCUM definitions or is derived from it, subject to a license from Regenstrief Institute, Inc. and The UCUM Organization. Your use of the UCUM table, UCUM codes, UCUM definitions also is subject to this license, a copy of which is available at http://unitsofmeasure.org. The current complete UCUM table, UCUM Specification are available for download at http://unitsofmeasure.org. The UCUM table and UCUM codes are copyright Â© 1995-2013, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved.

The CDA narrative block may contain the markup element to wrap a block of text so that it can be explicitly identified using its XML ID attribute, and referenced from elsewhere in the document. Specifically, structured entries may link to their equivalent narrative rendering in a content block using the XML ID (see CDA R2 Specification, section 4.3.5.1).

Production logic using the Business Name GraphicRef should assign the associated value to the referencedObject attribute.

SR Instances using TID 2006 have a Current Procedure Descriptions section specified using TID 2007. Source data in that template and from the General Study Module is mapped into the CDA Procedure Description section.

TID 1006 Subject Context allows identification of a different subject than the patient identified in the SR Patient IE. In the transformations of this Annex, only an identified fetus subject is supported as Subject Context for a Findings section. An SR section with a fetus subject context shall be mapped to a CDA section shall be in accordance with the Fetus Findings subsection Template 1.2.840.10008.9.9. This section is subsidiary to the top level Findings section; multiple SR fetus findings sections may be mapped to separate CDA Fetus Findings subsections.

For an included template of the single parent element style, the scoping business name and top level element are provided in italics in the invoking template table. This indicates this is data copied from the specification in the included template for the reader's convenience.

DICOM-20150324: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.8

While this entry may be a trigger for a tracking system for ensuring follow up on recommendations, the imaging study report only conveys the interpreting physician's recommendations.

Any SHALL conformance requirement on an element may use nullFlavor, unless nullFlavor is explicitly disallowed (as indicated by noNull, see SectionÂ 5.2.7 Value Conformance). SHOULD and MAY conformance requirements may also use nullFlavor. nullFlavor does not apply to conformance requirements on attributes.

These codes may be used as health information exchange search metadata in accordance with the IHE Radiology Technical Framework Cross-Enterprise Document Sharing for Imaging (XDS-I) Profile.

In accordance with CDA R2 (and HL7 v3 XML) extensibility rules, as described in CDA R2 Section 1.4, "locally-defined" XML markup may be specified where there is a need to communicate information for which there is no suitable representation in CDA R2. These extensions are described in the context of the templates where they are used. All such extensions use HL7 v3 Data Types used by CDA R2.

See ExampleÂ 10.5-2 âQuantity measurement observation example 2â, an example of a measurement using a topographical modifier qualifier.

The author participation allows the recording of an author for a section, equivalent to the TID 1002 âObserver Contextâ. Either a person or a device may be identified as the author for a section or subsection.

There may be other CDA-related standards to which an application may claim conformance. For example, IHE Patient Care Coordination Technical Framework specifies a Document Consumer actor with four options for conformance.

The keyword SHALL is associated with a minimum cardinality of at least 1; other keywords have a minimum cardinality of 0. If an element is required by SHALL, but is not known (and would otherwise be omitted without the SHALL requirement), it must be represented by a nullFlavor. SHALL allows the use of nullFlavor unless the requirement is on an attribute (nullFlavor does not apply to attributes), or the use of nullFlavor is explicitly precluded (see SectionÂ 5.2.7 Value Conformance and SectionÂ 5.3.2 Null Flavor).

A named category of like concepts (a semantic type) that is specified in the vocabulary declaration of an attribute in an information model. It constrains the intent of the coded element while deferring the binding of the element to a specific set of codes until later in the specification process.

Within this Standard, template versions are identified by the string "DICOM" and the date of adoption (represented as YYYYMMDD), separated by a hyphen (e.g., DICOM-20150523).

This Part constitutes an implementation guide for CDA, and is harmonized with the approach to standardized templates for CDA implementation guides developed by HL7. It also provides Business Names for data elements that link data in user terminology, e.g., collected by a report authoring application, to specific CDA encoded elements.

Other CDA implementation guides recommended using specific codes to assert no known content, for example SNOMED CT 160244002 "No known allergies" or 160245001 "No current problems or disability". Specific codes are still allowed; however, use of negationInd is an alternative, and the specific approach for each use will be specified in the associated template.

Identifier for a CDA Data Element, Attribute, or structure of Data Elements that corresponds to a business requirement for information exchange.

Masked. There is information on this item available but it has not been provided by the sender due to security, privacy, or other reasons. There may be an alternate mechanism for gaining access to this information.

This product includes all or a portion of the LOINCÂ® table, LOINC panels and forms file, LOINC document ontology file, and/or LOINC hierarchies file, or is derived from one or more of the foregoing, subject to a license from Regenstrief Institute, Inc. Your use of the LOINC table, LOINC codes, LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file also is subject to this license, a copy of which is available at http://loinc.org/terms-of-use. The current complete LOINC table, LOINC Users' Guide, LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file are available for download at http://loinc.org. The LOINC table and LOINC codes are copyright Â© 1995-2013, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. The LOINC panels and forms file, LOINC document ontology file, and LOINC hierarchies file are copyright Â© 1995-2013, Regenstrief Institute, Inc. All rights reserved.

Contains information related to the radiation exposure and protection of the patient, as may be required by national or local legal requirements or standards.

In TableÂ 5.2.3-1, the code attribute of the code element could be selected with the XPath expressionauthor/assignedAuthor/code/@code.

PROBE ORAL w/PROBE WELL FOR VITAL SIGNS 300 MONITOR. PROBE ORAL w/PROBE WELL FOR VITAL SIGNS 300 MONITOR. #111-02895-000. Add to quote. Probe Well Kit, OEM, ...

XML Schema Datatypes XML Schema Part 2: Datatypes Second Edition, World Wide Web Consortium, 2004 (http://www.w3.org/TR/xmlschema-2/)

Literal values to be encoded in CDA elements are represented in the mapping tables in normal font, as a string, or as a coded value triplet:

A SOP Instance Observation contains the DICOM Service Object Pair (SOP) Instance information for referenced DICOM composite objects. The SOP Instance act class is used to reference both image and non-image DICOM instances. The text attribute contains the DICOM WADO reference.

The Observation may have @negationInd attribute "true", which together with the code "ASSERTION" indicates that the finding was not observed, e.g., to represent "No finding of stroke".

Concept Domain names are similar to element Business Names in that they provide a public interface that is bound to specific values later in the document specification and production process. Concept Domains do not have a Value Conformance verb; the conformance verb is specified when the Concept Domain is bound to a specific value or value set (see SectionÂ 5.2.9.1).

The list items contain human readable displayable text using any of the narrative text structures permitted in section/text, including internal, external, or image references, or graphics. Processable structured data may be encoded in 10.1 Coded Observation or 10.5 Quantity Measurement entries in the section. Such observation entries SHOULD be linked to the corresponding item through the ID attribute of the item (see SectionÂ 10.1.2 and SectionÂ 10.5.1).

When an observation is unexpected or "actionable" (one type of which is denoted a "critical finding"), it may be flagged using the interpretationCode. For very abnormal findings the interpretationCode element SHALL be set to (AA, ObservationInterpretation, "abnormal alert"). Unexpected normal findings, e.g., no findings of disease when patient treatment had been planned on the presumption of disease, may also be flagged using interpretationCode (N, ObservationInterpretation, "normal").

COND: If this template is invoked from the Comparison Study section, procedure/participation MAY be used to identify the location (provider organization) at which the Comparison Study was performed.

Referenced Request Sequence (0040,A370) > Order Placer Identifier Sequence (0040,0026) > Universal Entity ID (0040,0032)

The DICOM Standard is structured as a multi-part document using the guidelines established in [ISO/IEC Directives, Part 2].

methodâCode may be used to encode study type, contrast use, challenge, views, positioning (CID 91 âFunctional Condition Present During Acquisitionâ, CID 92 âJoint Position During Acquisitionâ, CID 93 âJoint Positioning Methodâ, CID 94 âPhysical Force Applied During Acquisitionâ), etc.

The Request section narrative text block MAY include content blocks recording clinical decision support assessments of the request with respect to the indications, patient characteristics, and relevant guidelines. Each such text/content SHALL include an XML ID attribute that serves as the business name discriminator associated with an instantiation of the element. Even if only one content block is instantiated, the ID attribute shall be present.

MAY/NEED NOT: truly optional; can be included or omitted at the discretion of the content creator with no conformance implications

A pattern that describes the Content Items, Value Types, Relationship Types and Value Sets that may be used in part of a Structured Report content tree, or in other Content Item constructs, such as Acquisition Context or Protocol Context. Analogous to a Module of an Information Object Definition.

If (121005, DCM, "Observer Type") = (121007, DCM, "Device"), then (121012, DCM, "Device Observer UID")

Within the report section narrative blocks, RadLex codes may be included using the element and a URI pointing to the RadLex resource. elements may be embedded in the text at the location of the concept (within the scope of a content tag), or may be provided in a list at the end of the narrative block.

Elements and attributes that use the default value specified in CDA Specification are not shown. For example, the Section element has default attributes classCode='DOCSECT' and moodCode='EVN'; these are not listed in the templates. In accordance with the HL7 v3 specification, attributes with default values need not be included in instances, and their absence implies the default value.

Certain sections in a CDA Imaging Report have specific mappings from the DICOM SR header, or from specialized templates with content for particular uses.

The HL7v3 IVL Data Type used for effectiveTime requires the specification of absolute dates, rather than a date relative to the date of the report.

Inclusion of a subsidiary template includes the name of included template and its templateID, specified in the Subsidiary Template column of the invoking template table.

The legalAuthenticator MAY contain zero or one [0..1] sdtc:signatureText extension element. This provides a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act. The element is described in the HL7 CDA Digital Signature Standard.

Each template has a set of metadata, as specified in the HL7 Templates Specification. The metadata is presented as a table, as shown in TableÂ 5.1-1.

COND: If the observation site is not pre-coordinated in the observation/code, it SHALL be specified in the observation/targetSiteCode.

The most important diagnoses or other clinical conclusions that can be made from the imaging observations and other clinical information are recorded here. This section may include recommendations for additional imaging tests or other actions, as well as global assessments, such as BI-RADS Categories or the equivalent.

Data mapped from a specific Attribute in the interpreted DICOM image(s) is identified by the Attribute Name and Tag, represented in the mapping as:

This is generally not required, as the DICOM SOP Instance itself identifies relationships to the relevant other SOP Instances.

DICOM-20150324: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.22.4.63. This derivation uses DICOM-20150324 SOP Instance subsidiary template.

The Key Images section contains narrative description of and references to DICOM Image Information Objects that illustrate the findings of the procedure reported.

In an open template, additional elements and attributes allowed by the CDA Specification are not precluded by template constraints, unless there are applicable SHALL NOT template specifications.

IHE PCC TF IHE Patient Care Coordination Technical Framework, Revision 10.0, November 2014 (http://www.ihe.net/Technical_Frameworks/#pcc)

This derivation includes Purpose of Reference value set specified with DICOM CID 7003; directly incorporates descendant templates Purpose of Reference Observation, Referenced Frames, and Boundary Observation

ANSI/HL7 V3 XMLITSDT, R1-2004 HL7 Version 3 XML Implementation Technology Specification - Data Types, Release 1 - April 2004. [Note: this specific release version is required by CDA R2]

Use of Value Set LOINC Imaging Document Codes is harmonized with HL7 Consolidated CDA Templates for Clinical Notes, Release 2. DICOM CID 7001 âDiagnostic Imaging Report Headingâ, used in TID 2000 âBasic Diagnostic Imaging Reportâ, is a subset of the LOINC Imaging Document Codes.

This Part uses Business Names to identify and map common data elements from clinical imaging reports into the proper context-specific CDA/XML structure.

The serviceEvent/effectiveTime uses the IVL_TS data type with the low element required, for harmonization with Consolidated CDA release 1.1.

The observationMedia Entry provides an in-line graphic depiction of the section findings. It is referenced by a element in the section text. Typical uses are for graphic representation of findings (e.g., arterial tree diagrams) or in-line representations of key images.

HL7 CDAR2_IG_IHE_CONSOL HL7 Implementation Guide for CDAÂ® Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm, Draft Standard for Trial Use, July 2012 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258)

This Annex provided a transformation of SR documents based on TID 2006 Imaging Report With Conditional Radiation Exposure and Protection Information to HL7 CDA Release 2 Imaging Reports based on the HL7 Diagnostic Imaging Reports (DIR) Release 1.0 Informative specification Template 2.16.840.1.113883.10.20.6.

A Series Act contains the DICOM series information for referenced DICOM composite objects. The series information defines the attributes that are used to group composite instances into distinct logical sets. Each series is associated with exactly one study. Series Act clinical statements are only instantiated in the 9.8.7 DICOM Object Catalog section inside a 10.6 Study Act.

SR TID 2001 and TID 2002 allow Content Items to be INFERRED FROM NUM observations. The INFERRED FROM relationship is mapped to the entryRelationship with typeCode=SPRT, and the NUM observation is mapped to CDA Quantity Measurement entry subsidiary to its parent CDA Coded Observation or Quantity Measurement entry. This entryRelationship is shown in the Coded Observation and Quantity Measurement CDA Templates.

COND: The qualifier element for topographical modifier SHALL be present if the targetSiteCode does not fully specify the observation location in sufficient detail.

Other. The actual value is not an element in the value domain of a variable. (e.g., concept not provided by required code system).

The section text SHALL contain information related to the radiation exposure and protection of the patient, as is required by state/national legal requirements or standards, for example:

This templateId may be used to identify the template(s) used to generate/constrain the content of the section. This is in addition to the templateId of the section level template, and typically represents clinical sub-specialty requirements. See SectionÂ 5.1.1 on the structure and use of the templateId.

The template table may constrain values to a single fixed value, to a Value Set from which the value is to be drawn, or to a named Concept Domain. It may non-normatively reference a mapping from a DICOM SOP Instance or an HL7 message.

Clinical Trials: Template 1.2.840.10008.9.1 does not define attributes for clinical trials equivalent to those of the Patient, Study, and Series IEs (Clinical Trial Subject Module, Clinical Trial Study Module, Clinical Trial Series Module).

IHE Card Sup CIRC IHE Cardiology Technical Framework Supplement, Cardiac Imaging Report Content, Trial Implementation, July 2011 (http://www.ihe.net/Technical_Frameworks/#cardiology)

(123014, DCM, "Target Region") or (55111-9, LN, "Current Procedure Descriptions") > (123014, DCM, "Target Region")

The subject/relatedSubject/subject/name element is used to store the fetus ID, typically a pseudonym such as "fetus A". This shall be present even if only one fetus is identified in the document.

procedure/targetSiteCode may be used to encode the specific anatomic focus, and is not necessarily identical to documentationOf/serviceEvent/code/translation used for anatomic region in the CDA header. This may be derived from Body Part Examined (0018,0015), as mapped to SNOMED codes in Annex L âCorrespondence of Anatomic Region Codes and Body Part Examined Defined Termsâ in PS3.16, or from Anatomic Region Sequence (0008,2218).

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.

The substanceAdministration entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See SectionÂ 9.1.1.1.

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 SectionÂ 9.1.1.2).

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ANSI/HL7 V3 CPPV3MODELS, R1-2012 HL7 Version 3 Standard: Core Principles and Properties of Version 3 Models, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=58)

This template specifies the common set of structured entries that may be included in a CDA imaging report section, and an author participation for the section.

Constrained DICOM SR documents based on Imaging Report templates can be mapped to HL7 CDA Release 2 Imaging Reports based on Template 1.2.840.10008.9.1, as specified in SectionÂ 7.1. The SR report templates to which this transformation applies include:

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Per the CDA Standard, the legal authenticator, if present, must be a person, and the authentication applies to the human-readable narrative in section/text and any renderMultiMedia referenced content. Structured entries and external images referenced through linkHtml are not attested by the legal authentication.

This discrepancy is resolved in HL7v3 Data Types R2 to follow the convention used here, and the HL7 Structured Documents Working Group has approved the "pre-adoption" of the Data Types R2 approach in CDA implementations.

Thus the concept "follow-up within one year" needs to be encoded as a IVL with an effectiveTime/high element value one year after the date of the report.

COND: The XML ID attribute SHALL be present for a list or a list item if the content is referenced from elsewhere in the document.

A Purpose of Reference Observation describes the purpose of the DICOM composite object reference. Appropriate codes, such as externally defined DICOM codes, may be used to specify the semantics of the purpose of reference. When this observation is absent, it implies that the reason for the reference is unknown.

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 XML element

The recordTarget records the patient whose health information is described by the clinical document; it must contain at least one patientRole element.

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.

In the context of an Imaging Report, the section/text should document any contraindications to contrast administration or other procedure techniques that affected the selection or performance of the protocol.

The effectiveTime signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not represented in CDA.

If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element.

Each template is defined as being either "open" or "closed". In "open" templates, all of the features of the CDA Specification are allowed except as constrained by the templates. By contrast, a "closed" template specifies everything that is allowed and nothing further may be included.

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Note that there is no business name associated with this template. Rather, this template is an editorial convenience for template specification, and the Business Names for the elements of this template are logically part of the business name scope of the invoking template.

As noted in the CDA R2 specification, the document originator is responsible for ensuring that the narrative block contains the complete, human readable, attested content of the section. Structured entries support computer processing and computation, and are not a replacement for the attestable, human-readable content of the CDA narrative block.

SR Instances using TID 2006 have additional attributes of a comparison procedure specified using TID 2007, which is used in the Prior Procedure Descriptions section. The attributes of both TID 1005 and TID 2007 are source data in the TableÂ C.4-4 mapping.

SR TID 2000, TID 2005 and TID 2006 specify that imaging report elements are contained in sections, represented as CONTAINERs with concept name codes from CID 7001.

Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc.

COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode.

SHOULD/SHOULD NOT: a best practice or recommendation. There may be valid reasons to ignore a recommendation, but the full implications must be understood and carefully weighed before choosing to not adhere to the best practice.

Document structure for an Imaging Addendum Report, i.e., an appendage to an existing report document that contains supplemental information. The parent document content remains unaltered. The Addendum Report must be read together with its parent document for full context. Some institutions may have policies that forbid the use of Addendum Reports, and require revised reports with a complete restatement of the original documentation.

summary information on radiation exposure if ionizing is applied in the context of the current procedure (detailed specification of exposure is out of the scope of this textual summary).

A template inclusion may provide Concept Domain Vocabulary Binding or other vocabulary constraints, e.g., limiting an element in the included template to a specific value from its defined Value Set. These vocabulary constraints are specified in tabular form, as shown in TableÂ 5.2.9.1-1. The table is included in the additional requirements for the template, with a reference in the Value column of the template entry invoking the subsidiary template. The Value Conformance and Value specification columns are interpreted as in the templates tables.

Patient Study Module: Medical or clinical characteristics of the patient specified in the Patient Study Module are not mapped (see PS3.3 Section C.17.5 âObservation Context Encodingâ)

The CDA document management vocabulary includes a typeCode APND (append) relationship to a parent document. This relationship type is not supported in this specification; rather, append is effected by creating a replacement document with an 9.7 Addendum.

Provides a quality assessment for the image set identified by the invoking section. By default unless otherwise identified, applies to the image set interpreted by the document (typically a Study). If the quality rating applies to only a subset of the Study (e.g., a Series, or a specific Image), that subset shall be identified in the invoking section.

HL7 CDA R2 DIR IG, R1-2009 Health Level Seven Implementation Guide for CDA Release 2: Imaging Integration, Basic Imaging Reports in CDA and DICOM, Diagnostic Imaging Reports (DIR) Release 1.0 - Informative, 2009 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=13)

The report templates sponsored by the RSNA Radiology Reporting Initiative (http://www.radreport.org) adhere to this general section outline.

In publishing and making this document available, NEMA is not undertaking to render professional or other services for or on behalf of any person or entity, nor is NEMA undertaking to perform any duty owed by any person or entity to someone else. Anyone using this document should rely on his or her own independent judgment or, as appropriate, seek the advice of a competent professional in determining the exercise of reasonable care in any given circumstances. Information and other standards on the topic covered by this publication may be available from other sources, which the user may wish to consult for additional views or information not covered by this publication.

(121050, DCM, "Equivalent Meaning of Concept Name") > Concept Code Sequence (0040,A168) > Code Meaning (0008,0104) if present; otherwise Concept Name Code Sequence (0040,A043) > Code Meaning (0008,0104) [of the root content item].

The mapping of the value typically requires a transformation from the DICOM Value Representation or the HL7v2 Data Type representation to the CDA Data Type encoding. For example, transforming a DICOM Code Sequence attribute or an HL7v2 CWE field to a CD or CE Data Type requires a look up of the Coding Scheme OID.

HL7 v3-2014 HL7 Version 3 Interoperability Standards, Normative Edition 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=362]

Elements whose value may be drawn from a Value Set will have that Value Set identified in the Value column introduced by the keyword ValueSet.

If the sender wants to state 'no known', a negationInd can be used on the corresponding act (substanceAdministration, Procedure, etc.)

In Consolidated CDA r1.1, this was defined using a separate "Purpose of Reference Observation" template, which is included directly in this template specification.

No acute cardiopulmonary process. Round density in left superior hilus, further evaluation with CT is recommended as underlying malignancy is not excluded.

The information in this publication was considered technically sound by the consensus of persons engaged in the development and approval of the document at the time it was developed. Consensus does not necessarily mean that there is unanimous agreement among every person participating in the development of this document.

Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and sections by referring to templates, and constraints on the vocabulary used in those templates.

Based on local practice, clinical documents may be released before legal authentication. This implies that a clinical document that does not contain this element has not been legally authenticated.

CDA documents are encoded using the Extensible Markup Language (XML), and are marked up through hierarchically nested XML elements (tags). The Nesting Level column of the template tables identifies the hierarchical level of each element relative to the other elements in the table using the character right angle bracket '>'. Multiple levels of nesting are identified by multiple > characters.

DICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects. The DICOM Object Catalog section is not intended for viewing and may contain empty section text.

Additional specification information for the CDA narrative block can be found in the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.

The Procedure Technique entry allows the encoding of various parameters of the image acquisition. Other details may be found in other entries (e.g., procedural medication).

A Referenced Frames Observation contains a list of integer values for the referenced frames of a DICOM multi-frame image SOP instance. It identifies the frame numbers within the referenced SOP instance to which the reference applies. The observation identifies frames using the same convention as DICOM, with the first frame in the referenced object being Frame 1. A Referenced Frames Observation must be used if a referenced DICOM SOP instance is a multi-frame image and the reference does not apply to all frames.

Narrative or coded subsection that allows organization of content for a labeled topic (a particular organ or anatomic feature, a lesion, a tumor, etc.). The section.code shall be absent, but the section.title shall be present.

A CDA document instance in accordance with this Standard asserts its conformance to a template by inclusion of the specified templateID elements in the document, sections, and entries.

TID 1005 Procedure Study Context allows identification of a different procedure than the procedure identified in the SR Study IE as the context for the section observations. In the transformations of this Annex, only an identified comparison procedure is supported as Procedure Context, the SR section being transformed must be either Prior Procedure Descriptions or Previous Findings, and the CDA section shall be in accordance with the Comparison Study section Template 1.2.840.10008.9.4.

The text elements (and their children) MAY contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL. The text content of linkHtml MAY be either the visible text of the hyperlink, or a descriptor or identifier of the image.

ANSI/HL7 CDAÂ®, R2-2005 HL7 Version 3 Standard: Clinical Document Architecture (CDA) Release 2, 2005 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7)

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HL7 CDAR2_IG_GREENMOD4CCD HL7 Implementation Guides for CDAÂ® R2: greenCDA Modules for CCDÂ®, Release 1 - Informative, April 2011(http://www.hl7.org/implement/standards/product_brief.cfm?product_id=136)

Verifying Observer Sequence (0040,A073) > Verifying Observer Identification Code Sequence (0040,A088) [code value as identifier]

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):

The Consolidated CDA specification includes extensive examples of valid and invalid encodings, which may be useful for implementers.

The linkHtml may be associated with a markup element to specify a (limited resolution) copy of the image to be rendered in the narrative (e.g., a thumbnail); the renderMultiMedia element SHALL link to an observationMedia structured entry using the XML ID of that entry. As CDA does not allow use of an image as the linkHtml displayable hyper-linked content, the linkHtml should immediately follow the renderMultiMedia for the thumbnail.

The table cells contain human readable displayable text using any of the narrative text structures permitted in section/text, including internal, external, or image references, or graphics. Processable structured data may be encoded in 10.1 Coded Observation or 10.5 Quantity Measurement entries in the section. Such observation entries SHOULD be linked to the corresponding row through the ID attribute of the row (see SectionÂ 10.1.2 and SectionÂ 10.5.1).

In Consolidated CDA r1.1, this was defined using separate "Referenced Frames Observation" and "Boundary Observation" templates, which are included directly in this template specification.

ps3-20:accessionNumber - The accessionNumber extension allows for the clear identification of the imaging department identifier for a service request (order). While this identifier could be conveyed as another id for the inFulfillmentOf/Order element, there is no reliable way in that context to distinguish it from the Placer Order Number. As this is a primary management identifier in departmental workflows, a distinct local markup is defined. This extension uses the II Data Type.

Most of the codes in Value Set LOINC Imaging Document Codes are pre-coordinated with the imaging modality, body part examined, and/or specific imaging method. When pre-coordinated codes are used, any coded values elsewhere in the document describing the modality, body part, etc., must be consistent with the document type code. Local codes used for report types may be included as a translation element in the code.

When a measurement is out of normal range, it may be flagged using the interpretationCode. Very abnormal values, often denoted as exceeding "panic limits", or as "actionable" or "critical findings", may have values such as (LL, ObservationInterpretation, "low alert"), (HH, ObservationInterpretation, "high alert"), or (AA, ObservationInterpretation, "abnormal alert").

The Coded Observation entry MAY include an actRelationship of type SUBJ (has subject) to a subsidiary Coded Observation (recursively invoking this same template). This allows the constructions of complex clinical statements.

The date and time of the imaging procedure is indicated in the serviceEvent/effectiveTime element; the date and time of the interpretation is in the clinicalDocument/effectiveTime.

Data mapped from a specific Attribute in an SR Content Item uses the triplet to identify the Content Item, with the > character and the specific attribute name and tag:

A Quantity Measurement records quantitative measurements such as linear, area, volume, and numeric measurements. If based on image data, a reference to the image may be present.

This Annex defines the transformation of an Enhanced SR SOP Instance to a CDA instance. The following constraints apply to such SOP Instances:

(122142, DCM, "Acquisition Device Type") or (55111-9, LN, "Current Procedure Descriptions") > (122142, DCM, "Acquisition Device Type")

HL7 CDAR2_IG_CCDA_CLINNOTES_R2 HL7 Implementation Guide for CDAÂ® Release 2: Consolidated CDA Templates for Clinical Notes, Release 2 - US Realm, Draft Standard for Trial Use, November 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379)

COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode.

The CDA narrative block MAY contain the markup element to include graphical content, e.g., a coronary tree diagram or myocardial wall motion "bulls-eye chart". The renderMultiMedia element SHALL link to an observationMedia structured entry using the XML ID of that entry (see SectionÂ 10.3.1 and CDA R2 Specification, section 4.3.5.6).

For example, a linkHtml reference could be used to link an actionable finding in the 9.6 Impression section to the specific, detailed measurement evidencing a problem that was identified in the text of the 9.5 Findings section.

CDA Template 1.2.840.10008.9.1 requires a minimum of an Imaging Procedure Description section and an Impression section.

The namespace for extensions defined in this Standard is "urn:dicom-org:ps3-20", which is aliased in this Standard as "ps3-20". Extensions defined in this Standard are:

Production logic based on Business Names needs to provide a mechanism for assignment of a value to the nullFlavor attribute as an alternative for a value for the element. Specification of such production logic is outside the scope of this Standard.

The following terms used in this Part of the DICOM Standard are defined in HL7 Core Principles and Properties of Version 3 Models:

Also, the ID of this template is not represented in a templateID element. Rather, the templateID of the invoking template implicitly includes the elements specified by this template.

The effectiveTime of the encompassingEncounter represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.

The documentationOf/serviceEvent may include as a participant the physician reading the study, equivalent to DICOM attribute (0008,1060), and other healthcare professional participants in the procedure (e.g., the surgical performer in an interventional procedure).

The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.

Procedure Context: The mapping allows identification of a different procedure than the procedure identified in the SR Study IE only as context for a Prior Procedure Descriptions section.

The Procedure entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See SectionÂ 9.1.1.1.

This templateId may be used to identify the template(s) used to generate/constrain the content of the report. This element is in addition to the templateId of the document level template, and typically represents clinical sub-specialty requirements. See SectionÂ 5.1.1 on the structure and use of the templateId.

COND: If modality is CT, MG, NM, PT, XR, XA, or XF, the section SHOULD contain a procedure entry for the exposure of the patient to ionizing radiation.

Patient Cables. NMT Monitoring Cable (Electromyography). Overview. The EMG patient cable provides a secure connection to your EMG electrode and the STIMPOD.

Section/text in the CDA document contains the narrative text (attested content) of the document. Section/text shall be generated from all the Content Items subsidiary to a section CONTAINER of the SR document, such that the full meaning is be conveyed in an unambiguous manner in the narrative block.

A structured entry representation of the act of communication MAY be included in the section. This entry does not necessarily represent the entirety of the act as described in the narrative text, e.g., the communication method and actual content of the communication is not represented, nor whether the receiver acknowledged the communication ("read-back"). The act/text/reference element SHALL include an XML IDREF value pointing to the associated narrative content block.

NEMA disclaims liability for any personal injury, property, or other damages of any nature whatsoever, whether special, indirect, consequential, or compensatory, directly or indirectly resulting from the publication, use of, application, or reliance on this document. NEMA disclaims and makes no guaranty or warranty, expressed or implied, as to the accuracy or completeness of any information published herein, and disclaims and makes no warranty that the information in this document will fulfill any of your particular purposes or needs. NEMA does not undertake to guarantee the performance of any individual manufacturer or seller's products or services by virtue of this standard or guide.

The section may include reference to one or more DICOM Dose Report SOP Instances that provides a detailed record of exposure.

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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.

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

For radiology reports, this capability may be used to tag concepts in the narrative block to concepts defined in the RadLex terminology (http://www.radlex.org), developed by the Radiological Society of North America. The RadLex coded vocabulary is a useful tool for indexing report content for data mining purposes. It is not intended to be a complete grammar for expression of clinical statements, but rather a lexicon for tagging concepts of interest.

The template table may contain elements without a value specification, and without a Business Name. These are typically id elements. The application creating the document instance shall fill these elements with appropriate values.

Production logic based on Business Names should allow single instantiations of elements without a discriminator; for instance, SectionÂ 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.

The Coding Scheme Designator is a simple human readable identifier of the code system, and corresponds to the optional codeSystemName attribute of the CD or CE element. The CDA Specification requires the Code System OID to be encoded in the codeSystem attribute of the CD or CE element. The corresponding OID for each Coding Scheme Designator is provided in Annex 8 âCoding Schemesâ in PS3.16. The Code Meaning is encoded in the displayName attribute of the CD or CE element.

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

The SR sample document encoding includes information on the SR document body tree depth (column 1: SR Tree Depth), nesting level for nested artifacts such as sequences and sequence items (column 2: Nesting), DICOM attribute names (column 3: Attribute), DICOM tag (column 4: Tag), the DICOM attribute value representation (Column 5: VR as specified in PS3.5), the hexadecimal value of value length (column 6: VL (hex)) and the sample document attribute values (column 7: Value).

COND: If the documented service utilizes ionizing radiation, a 9.8.5 Radiation Exposure and Protection Information section MAY be present.

TID 2000, TID 2005 and TID 2006 specify inclusion of TID 1001 Observation Context as Mandatory, but TID 1001 has no content if all aspects of context are inherited, as under this constraint.

The HL7 Structured Documents Working Group coordinates markup extensions that have been defined for implementation guides published by HL7, IHE, DICOM, and other organizations. See http://wiki.hl7.org/index.php?title=CDA_R2_Extensions

Procedure indications may also be specified as SR content items in the (18785-6, LN, "Indications for Procedure") CONTAINER, which may be mapped to the CDA instance in accordance with SectionÂ C.4.3. It is an implementation decision how to handle multiple representations of indications in the SR document.

Template identifiers (templateId) are assigned for each document, section, and entry level template. When valued in an instance, the template identifier signals the imposition of a set of template-defined constraints. The value of this attribute (e.g., @root="2.16.840.1.113883.10.20.22.4.8") provides a unique identifier for the template in question.

DICOM-20150324: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.6. This derivation makes Series conditional (required for Object Catalog) to support use in Comparison Study reference, and uses DICOM-20150324 Series Act subsidiary template.

COND: entryRelationship SHALL NOT be present in a 10.8 SOP Instance Observation included within a 9.8.7 DICOM Object Catalog section, and MAY be present otherwise.

The single parent element style is typical for the top level Document, Section, and Entry templates, and the parent element is of the HL7 v3 RIM act class. Inclusion of such a template therefore involves an actRelationship element; that actRelationship element is specified in the invoking template.

„1440 180. Rasta: 123. Populiaresni viršuje, Pigesni viršuje, Brangesni viršuje ... Monitorius ASUS ROG Strix XG32WCS, 31.5", 2560 x 1440, 180 Hz,.

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

An inFulfillmentOf element represents the Placer Order. There may be more than one inFulfillmentOf element in the case where a single report is fulfilling multiple orders. There SHALL be one inFulfillmentOf/order for each distinct Order associated with the report.

This section provides a separate section to describe the study interpreter's recommendations for follow-up studies or procedures.

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 SectionÂ 9.1.1.1).

When invoked from the (current) 9.3 Imaging Procedure Description, procedure/code SHALL be identical to documentationOf/serviceEvent/code in the CDA header.

The Business Name for the text element of the 9.2 Clinical Information report section is "ImagingReport:ClinicalInformation:Text"

SR allows sections to be qualified by observation context, using TID 1001 and its subsidiary templates. This capability is constrained in this mapping.

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.

For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget/PatientRole/Patient in the CDA header. Information on the fetus is mapped to subject/relatedSubject/SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.

The cardiomediastinum is within normal limits. The trachea is midline. The previously described opacity at the medial right lung base has cleared. There are no new infiltrates. There is a new round density at the left hilus, superiorly (diameter about 45mm). A CT scan is recommended for further evaluation. The pleural spaces are clear. The visualized musculoskeletal structures and the upper abdomen are stable and unremarkable.

XML elements may have attributes, encoded as "=" pairs within the element tag. Such attributes are identified using the character at sign '@'.

SR documents can be thought of as consisting of a document header and a document body, corresponding to a CDA document header and body. The header includes the modules related to the Patient, Study, Series, and Equipment Information Entities, plus the SR Document General Module, as specified in PS3.3. The SR Document Content Module contains the content tree (structured content) of the document body. Note, however, that DICOM SR considers the root content item, including the coded report title, and some context-setting content items as part of the document body content tree, but these constitute part of the CDA header. See FigureÂ C-1.

The specification of a representation of Data Types for use in Business Name-based report production logic is outside the scope of this Standard.

The data type associated with each element/attribute is specified, as described in the CDA Specification and its referenced HL7v3 Data Types Release 1. Elements that are simply tags with subsidiary content only of nested elements, e.g., RIM class clone names, have the Data Type column empty.

XML Path Language (XPath) notation is used to identify the XML elements and attributes within the CDA document instance to which various constraints are applied. The implicit context of these expressions is the root node of the document, and traversing the path to the root node of the relevant template. This notation provides a mechanism that will be familiar to developers for identifying parts of an XML document.

HL7 Data Types CD (Concept Descriptor) and CE (Coded With Equivalents) allow a translation code element, which allows the encoding of the same concept in an alternate coding system. This supports the encoding of both an originally entered (local) code, and a code specified for cross-system interoperability.

[ISO/IEC Directives, Part 2] ISO/IEC. 2016/05. 7.0. Rules for the structure and drafting of International Standards. http://www.iec.ch/members_experts/refdocs/iec/isoiecdir-2%7Bed7.0%7Den.pdf .

In each inFulfillmentOf/order there SHALL be one order/id for the Placer Order Number (0040,2016). There SHALL be one order/ps3-20:accessionNumber for the DICOM Accession Number (0008,0050) associated with the order. The ps3-20:accessionNumber SHALL be Data Type II; it SHALL have a UID root attribute identifying its assigning authority, and the DICOM Accession Number SHALL be in the extension attribute.

Many Data Types encode their values in attributes, rather than character data. For example, the URL Data Type encodes its value in the value attribute within the element tag, e.g., . Within this specification, the attribute(s) that hold the value are not identified, except where specific constraints apply.

Data mapped from an HL7v2 field in the order for the study is identified by the Element Name and Segment Field identifier:

The Radiation Exposure and Protection Information section defined in SR TID 2006 is specified using TID 2008, which provides additional source data for mapping into the equivalent CDA subsection of the Imaging Procedure Description section.

HL7 CDA Digital Signatures HL7 Implementation Guide for CDAÂ® Release 2: Digital Signatures and Delegation of Rights, Release 1 - DSTU, October 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=375)

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

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.

The template table may constrain values or vocabularies to be used with an element or attribute. Value constraints include a conformance verb (SHALL, SHOULD, MAY, etc.) as defined in SectionÂ 5.2.5, and specified in the Value Conformance column of the template tables.

The Imaging Procedure Description section records the technical details of the procedure and may include information about protocol, imaging device, contrast, radiation dose, medications administered (sedation, stress agents), etc.

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.

Inclusion of a site name in a labeled subsection title (see SectionÂ 9.8.9) does not imply a finding site for observations within that subsection. The title is not semantically part of the post-coordination, and target sites must be explicitly identified.

A Study Act contains the DICOM study information that defines the characteristics of an imaging study performed on a patient. An imaging study is a collection of one or more series of medical images, presentation states, SR documents, overlays, and/or curves that are logically related for the purpose of diagnosing a patient. Each study is associated with exactly one patient. A study may include composite instances that are created by a single modality, multiple modalities, or by multiple devices of the same modality. The study information is modality-independent.

The value of type ED SHALL contain an in-line encoding of a graphic using base64. The element, if present, SHALL reference a URI for the same image as included in-line.

TID 2005 Transcribed Diagnostic Imaging Report specifies a section structure for the Key Images section of an SR, which allows mapping into the equivalent CDA subsection of the Impression section.

Single values of Data Type CD (Concept Descriptor) or CE (Coded With Equivalents) are specified in the template tables with the triplet notation specified in PS3.16:

ImagingReport:Study:Modality and ImagingReport:Study:AnatomicRegionCode may be mapped from attributes in the root CONTAINER, if present there as in TID 2000, or in the Current Procedure Descriptions section CONTAINER, if present there as in TID 2006.

Consolidated CDA Implementation Guide Section 2.8 includes recommended best practices for Document Recipients displaying CDA documents.

SNOMED CTÂ® Systematized Nomenclature of Medicine - Clinical Terms, International Release, International Health Terminology Standards Development Organisation (IHTSDO), January 2015

Observation Context: The mapping does not support changing the observation context for the report as a whole from its default context, as specified in the Patient, Study, and Document Information Entities (see PS3.3 Section C.17.5 âObservation Context Encodingâ)

Mandatory CDA elements for which there is no corresponding source data in the SR SOP Instance may be coded with a nullFlavor attribute (see SectionÂ 5.3.2).

When invoked from the (current) 9.3 Imaging Procedure Description, procedure/methodCode used for modality SHALL be identical to documentationOf/serviceEvent/code/translation used for modality in the CDA header (see SectionÂ 8.2.4.1).

SR TEXT Content Items are mapped to Coded Observation entries, but the code is a nullFlavor with the text content in originalText.

The Key Images section SHOULD include 10.8 SOP Instance Observation entries equivalent to the linkHtml image references.

Within each documentationOf element, there is one serviceEvent element. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the primary vocabulary to use for describing this event, identified as Procedure Code.

For transformation of the SR content into the CDA header, the target elements of the CDA instance are listed in TableÂ C.3-1 by their Business Names, together with the recommended source in an SR instance. This allows the transforming application to "pull" the relevant information from the SR to populate the CDA header.

This entry SHALL have a participant, the irradiation authorizing person who is the clinician responsible for determining that the irradiating procedure was appropriate for the indications.

Records details about the reason for the procedure. This section may include the pre-procedure diagnosis or diagnoses as well as one or more symptoms that contribute to the reason the procedure is being performed.

The Observation code element has an associated Concept Domain ObservationType. A representative binding for this Concept Domain is to the value (ASSERTION, actcode[2.16.840.1.113883.5.4], "Assertion"), providing an assertion of a finding concept in the value element.

LOINCÂ® is a registered United States trademark of Regenstrief Institute, Inc. A small portion of the LOINC table may include content (e.g., survey instruments) that is subject to copyrights owned by third parties. Such content has been mapped to LOINC terms under applicable copyright and terms of use. Notice of such third party copyright and license terms would need to be included if such content is included.

Additionally, constraints specifying Value Sets include a coding strength conformance CWE (Coded With Extensibility) or CNE (Coded with No Extensibility), as defined in Core Principles and Properties of HL7 Version 3 Models, Release 1.

Within the template, the keyword COND (conditional) may be present. In this case, the specification of the condition, and the conformance verbs associated with the condition being true or false, are described below the table in a paragraph flagged with the COND keyword.

The Key Images section text SHALL contain image references using linkHtml elements, where @href is a valid Web Access to DICOM Persistent Object (WADO) URL. See SectionÂ 9.1.1.5. The text content of linkHtml should be either visible text of the hyperlink, or a descriptor or identifier of the image; it may be associated with a (limited resolution) copy of the image (see SectionÂ 9.8.6.3).

A full discussion of the representation of data types and vocabulary is outside the scope of this document; for more information, see the HL7 V3 specifications on Abstract Data Types R1 and XML Data Types R1 referenced in the CDA Specification.

A section may contain CDA entries that represent clinical statements in coded form (using the 10.1 Coded Observation template), numeric measurements (using the 10.5 Quantity Measurement template), images to be displayed in the narrative block (using the 10.3 observationMedia template, and invoked from a renderMultiMedia element), or references to external images or annotated images (using the 10.8 SOP Instance Observation template).

For example, if a patient arrives at an Emergency Department unconscious and with no identification, a null flavor is used to represent the lack of information. The patient's birth date could be represented with a null flavor of "NAV", which is the code for "temporarily unavailable". When the patient regains consciousness or a relative arrives, we expect to be able to obtain the patient's birth date.

This template specifies a structure and Business Names for table markup in the narrative text, as described in the CDA Specification section 4.3.5.9, typically used for a table of measurements. The table may be of arbitrary size.

The ObservationMedia entry SHALL include an XML ID attribute (not to be confused with the id element of the act class) used as a target of a element in the section/text narrative block of the parent section. See SectionÂ 9.1.1.3.

COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode.

There may be more than one documentationOf/serviceEvent element if the report is interpreting multiple DICOM Studies. There may also be multiple reports for a single DICOM Study.

(121065, DCM, "Procedure Description") , if present, or (121023, DCM, "Procedure Code") > Code Meaning (0008,0104)

In simple procedures, the physician reading the study is identified in the Author or LegalAuthenticator participation on the ClinicalDocument, and does not need to be re-identified in this element. The technologist performing the imaging may be identified in this element as a secondary performer, since the interpreting physician is the principal performer responsible for the service event.

HL7 Templates HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1 - DSTU, October 2014 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=377)

THE UCUM TABLE (IN ALL FORMATS), UCUM DEFINITIONS, AND SPECIFICATION ARE PROVIDED "AS IS." ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.

DICOM-20150324: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.14. This derivation includes Units of Measure specified with DICOM value set for UCUM (CID 82 âMeasurement Unitâ), equivalent to C-CDA specified value set (UCUM Units of Measure (case sensitive) 2.16.840.1.113883.11.12839); addition of optional interpretationCode and actionable priority

A superseded version that the present document wholly replaces (typeCode =RPLC). Documents may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report.

De-identified Documents: There is no CDA implementation guidance from HL7 for de-identified documents, other than general rules for using the MSK null flavor (see SectionÂ 5.3.2). There is no CDA capability equivalent to the Encrypted Attributes Sequence (see PS3.3 Section C.12.1.1.4.1 âEncrypted Attributes Sequenceâ) for carrying encrypted re-identification data.

THE LOINC TABLE (IN ALL FORMATS), LOINC PANELS AND FORMS FILE, LOINC DOCUMENT ONTOLOGY FILE, AND LOINC HIERARCHIES ARE PROVIDED "AS IS." ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.

The text element within the section stores the narrative to be rendered, as described in the CDA R2 specification, and is referred to as the CDA narrative block.

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.

IHE RAD TF IHE Radiology Technical Framework, Revision 13.0, July 2014 (http://www.ihe.net/Technical_Frameworks/#radiology)

Values of Data Type CS (Coded Simple Value) have a fixed code system defined in the CDA Specification, and are simple strings. The template tables identify only the constraint on the code value, and do not specify the fixed code system nor the code meaning (display name), which are not encoded in the CDA instance.

SR TID 1400, TID 1401, TID 1402, and TID 1404 allow NUM Content Items to be INFERRED FROM SCOORD observations, which are SELECTED FROM IMAGE observations. This Annex does not specify the transformation for SCOORD observations; these would use the CDA Region Of Interest entry, which PS3.20 forbids (see SectionÂ 9.1.2.4).

COND: If the observation site is not pre-coordinated in the observation/code or observation/value, it SHALL be specified in the observation/targetSiteCode.

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