languageCode 1..1 SHALL CS SHALL CNE Value Set Languages SetId setId 0..1 MAY II versionNumber 1..1 COND INT Patient[*] recordTarget 1..* SHALL > patientRole 1..1 SHALL * >@ @ID 1..1 XML ID >> id 1..* SHALL II IDIssuer >>@ root 1..1 SHALL UID Issuer of Patient ID Qualifiers Sequence (0010,0024) > Universal Entity ID (0040,0032) ID >>@ extension 1..1 SHALL ST Patient ID (0010,0020) Addr >> addr 1..* SHALL AD Tele >> telecom 1..* SHALL TEL >> patient 1..1 SHALL Name >>> name 1..1 SHALL PN Patient’s Name (0010,0010) Gender >>> 1..1 SHALL CE SHALL CNE Value Set Patient’s Sex (0010,0040) Map value “O” to nullFlavor UNK BirthTime >>> birthTime 1..1 SHALL TS Patient’s Birth Date (0010,0030) + Patient’s Birth Time (0010,0032) >> 0..1 MAY
Findings Template ID 2.16.840.1.113883.10.20.6.1.2 Name Findings Effective Date (Date of Final Text adoption) Version Label DICOM-yyyymmdd Status Draft (will change to Approved on Final Text adoption) Description Records clinically significant observations confirmed or discovered during the procedure. Classification CDA Section Level Relationships Invoked by Document Level Template Context Open/Closed Open Revision History From Consolidated CDA r1.1 DICOM-yyyymmdd: Added optional subsections and entries Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template Findings section > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..* SHALL II > code 1..1 SHALL CD SHALL (59776-5, LOINC, "Procedure Findings") Title > title 1..1 SHALL ST Text > text 1..1 ED > component 0..* MAY >> section 1..1 SHALL > component 0..* MAY
>>@ @classCode 1..1 SHALL SHALL SBADM >>@ @moodCode 1..1 SHALL SHALL EVN >>> code 1..1 SHALL (440252007, SNOMED, of >>> doseQuantity 0..1 SHOULD PQ >>> consumable 1..1 SHALL >>>> 1..1 SHALL >>>>> material 1..1 SHALL code 1..1 SHALL CE SHOULD CWE Value Set or PET original Text 0..1 SHOULD ED text 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: information on the indications for the procedure the name of the "Irradiation Authorizing" person who is the clinician responsible for determining that the irradiating procedure was appropriate for the indications. 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). information on the radioactive substance administered if radioactive substance is administered in the context of the current procedure. Note: Compare to PS3.16 TID 2008 Radiation Exposure and Protection Information. Dose
> Code Value (0008,0100) SH 0006 11123 > Coding Scheme Designator (0008,0102) SH 0008 99WUHID > Code Meaning (0008,0104) LO 000c X-Ray Study %enditem %endseq Referenced Performed Procedure Step Sequence (0008,1111) SQ ffffffff %endseq Patient's Name (0010,0010) PN 0008 Doe^John Patient ID (0010,0020) LO 000a 0000680029 Patient's Birth Date (0010,0030) DA 0008 19641128 Patient's Sex (0010,0040) CS 0002 M Study Instance UID (0020,000d) UI 002e 1.2.840.113619.2.62.994044785528.114289542805 Series Instance UID (0020,000e) UI 0036 1.2.840.113619.2.62.994044785528.20060823223142485052 Study ID (0020,0010) SH 0008 10523475 Series Number (0020,0011) IS 0004 560 Instance Number (0020,0013) IS 0006 07851 1 Value Type (0040,a040) CS 000a CONTAINER 1 Concept Name Code Sequence (0040,a043) SQ ffffffff 1 %item 1 > Code Value (0008,0100) SH 0008 18782-3 1 > Coding Scheme Designator (0008,0102) SH 0002 LN 1 > Code Meaning (0008,0104) LO 000c X-Ray Report 1 %enditem 1 %endseq 1 Continuity Of Content (0040,a050) CS 0008 SEPARATE Verifying Observer Sequence (0040,a073) SQ ffffffff %item > Verifying Organization (0040,a027) LO 001a World University Hospital > Verification DateTime (0040,a030) DT 000e 20060827141500
> Verifying Observer Name (0040,a075) PN 0012 Blitz^Richard^^^MD > Verifying Observer Identification Code Sequence (0040,a088) SQ ffffffff %item >> Code Value (0008,0100) SH 0008 08150000 >> Coding Scheme Designator (0008,0102) SH 0008 99WUHID >> Code Meaning (0008,0104) LO 0016 Verifying Observer ID %enditem %endseq %enditem %endseq Referenced Request Sequence (0040,a370) SQ ffffffff %item > Accession Number (0008,0050) SH 0008 10523475 > Referenced Study Sequence (0008,1110) SQ ffffffff %item >> Referenced SOP Class UID (0008,1150) UI 001a 1.2.840.10008.5.1.4.1.1.1 >> Referenced SOP Instance UID (0008,1155) UI 003c %enditem %endseq > Study Instance UID (0020,000d) UI 002e 1.2.840.113619.2.62.994044785528.114289542805 > Requested Procedure Description (0032,1060) LO 0020 CHEST TWO VIEWS, PA AND LATERAL > Requested Procedure Code Sequence (0032,1064) SQ ffffffff %item >> Code Value (0008,0100) SH 0006 11123 >> Coding Scheme Designator (0008,0102) SH 0008 99WUHID >> Code Meaning (0008,0104) LO 000c X-Ray Study %enditem %endseq
> Requested Procedure ID (0040,1001) SH 0006 123453 > Reason for the Requested Procedure (0040,1002) LO 0014 Suspected lung tumor > Placer Order Number/Imaging Service Request (0040,2016) LO 0006 123451 > Filler Order Number/Imaging Service Request (0040,2017) LO 0006 123452 %enditem %endseq Performed Procedure Code Sequence (0040,a372) SQ ffffffff %item > Code Value (0008,0100) SH 0006 11123 > Coding Scheme Designator (0008,0102) SH 0008 99WUHID > Code Meaning (0008,0104) LO 000c X-Ray Study %enditem %endseq Current Requested Procedure Evidence Sequence (0040,a375) SQ ffffffff %item > Referenced Series Sequence (0008,1115) SQ ffffffff %item >> Referenced SOP Sequence (0008,1199) SQ ffffffff %item >>> Referenced SOP Class UID (0008,1150) UI 001a 1.2.840.10008.5.1.4.1.1.1 >>> Referenced SOP Instance UID (0008,1155) UI 003c %enditem %item >>> Referenced SOP Class UID (0008,1150) UI 001a 1.2.840.10008.5.1.4.1.1.1 >>> Referenced SOP Instance UID (0008,1155) UI 003c
1.6.1.1.1 %endseq 1.6.1.1.1 %enditem 1.6.1.1 %endseq 1.6.1.1 %enditem 1.6.1 %endseq 1.6.1 %enditem 1.6 %endseq 1.6 %enditem 1.7 %item 1.7 > Relationship Type (0040,a010) CS 0008 CONTAINS 1.7 > Value Type (0040,a040) CS 000a CONTAINER 1.7 > Concept Name Code Sequence (0040,a043) SQ ffffffff 1.7 %item 1.7 >> Code Value (0008,0100) SH 0006 1.7 >> Coding Scheme Designator (0008,0102) SH 0004 DCM 1.7 >> Code Meaning (0008,0104) LO 000c Impressions 1.7 %enditem 1.7 %endseq 1.7 > Continuity Of Content (0040,a050) CS 0008 SEPARATE 1.7 > Content Sequence (0040,a730) SQ ffffffff 1.7.1 %item 1.7.1 >> Relationship Type (0040,a010) CS 0008 CONTAINS 1.7.1 >> Value Type (0040,a040) CS 0004 TEXT 1.7.1 >> Concept Name Code Sequence (0040,a043) SQ ffffffff 1.7.1 %item 1.7.1 >>> Code Value (0008,0100) SH 0006 1.7.1 >>> Coding Scheme Designator (0008,0102) SH 0004 DCM 1.7.1 >>> Code Meaning (0008,0104) LO 000a Impression 1.7.1 %enditem 1.7.1 %endseq 1.7.1 >> Text Value (0040,a160) UT 009c No acute cardiopulmonary process. Round density in left superior hilus, further evaluation with CT is recommended as underlying malignancy is not excluded. 1.7.1 %enditem 1.7 %endseq
CID 5000 Languages Context Group ID 5000 comprises the language tag coding scheme of RFC 30664646. The Coding Scheme Designator (0008,0102) shall be RFC3066IETF4646. Note The RFC 30664646 coding scheme is constructed from a primary subtag component encoded using the language codes of ISO 639, plus two codes for extensions for languages not represented in ISO 639. The code optionally includes a second additional subtag components, for scripts encoded using the four letter codes of ISO 15924, and for regions encoded using the two letter country codes of ISO 3166, or a language code extension registered by the Internet Assigned Names Authority. RFC 30664646 may be obtained at RFC 30664646 obsoletes RFC 3066 and RFC 1766, but is forward compatible with those specifications. ISO 639 codes may be obtained at . The two letter country codes of ISO 3166 may be obtained at https://www.iso.org/obp/ui/#search/code/ IANA language tag registrations may be obtained at In previous editions of the Standard, this Context Group formerly included the three letter language codes of ISO 639-2/B, using Coding Scheme Designator ISO639_2, or the langue codes of RFC 3066, using Coding Scheme Designator RFC3066, and several IANA-registered language code extensions, using Coding Scheme Designator IANARFC1766. RFC 3066 identifies a preference for the ISO 639-1 two letter codes to the ISO 639-2 three letter codes, and the ISO 639-2/T (terminology) subset to the ISO 639-2/B (bibliographic) subset. In previous editions of the Standard, this Context Group provided only language identifiers, with national or regional variant identified in a separate attribute or Content Item. CID 6096 Pregnancy Status Type: Extensible Version: 20040112 Table CID 6096. Pregnancy Status Coding Scheme Designator Code Value Code Meaning SNOMED CT Concept ID Equivalent SRT F-81890 not pregnant 60001007 SRT F-84094 possible pregnancy 102874004 SRT F-84000 patient currently pregnant 77386006 SRT R-41198 Unknown 261665006