languageCode 1..1 SHALL CS SHALL CNE ValueSet 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 ValueSet 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
>>> name 1..* SHALL ON Issuer of Patient ID (0010,0021) >>> telecom 0..* SHOULD TEL >>> addr 0..* SHOULD AD legalAuthenticator 0..1 MAY SigningTime > time 1..1 SHALL TS > signatureCode 1..1 SHALL CS SHALL S > assignedEntity 1..1 SHALL SignerID >> id 1.* SHALL II SignerAddr >> addr 1.* SHALL AD SignerTel >> telecom 1..* SHALL TEL >> assignedPerson 1..1 SHALL SignerName >>> name 1..1 SHALL PN > 0..1 MAY ED Author[*] author 1..* SHALL > time 1..1 SHALL TS > assignedAuthor 1..1 SHALL * >@ @ID 1..1 COND XML ID >> id 1.* SHALL II Addr >> addr 1.* SHALL AD Tel >> telecom 1..* SHALL TEL >> assignedPerson 1..1 SHALL Name >>> name 1..1 SHALL PN Recipient[*] 0..* MAY > intendedRecipient 1..1 SHALL
>@ @classCode 1..1 SHALL CS SHALL ASSIGNED * >@ @ID 1..1 XML ID Addr >> addr 0.* MAY AD Tel >> telecom 0..* MAY TEL >> 0..1 MAY Name >>> name 1..1 SHALL PN >> 0..1 MAY Org >>> name 1..1 SHALL ON custodian 1..1 SHALL > 1..1 SHALL >> 1..1 SHALL >>> id 1.* SHALL II >>> name 1..1 SHALL ON >>> addr 1..1 SHALL AD >>> telecom 1..1 SHALL TEL 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. templateId - contentTemplate 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 subspecialty requirements. See on the structure and use of the templateId. Notes: The IHE MRRT profile defines a "dcterms.identifier" that may be used for this templateId.
InformationRecipient/intendedRecipient and @ID 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). COND: If there are multiple informationRecipient elements, each intendedRecipient element SHALL include an XML ID attribute that serves as the business name discriminator associated with the instance of the element. Figure 18: informationRecipient example <informationRecipient> <intendedRecipient classCode="ASSIGNED"> <informationRecipient> <name> <given>Henry</given> <family>Seven</family> </name> </informationRecipient> <receivedOrganization> <name>Good Health Clinic</name> </receivedOrganization> </intendedRecipient> </informationRecipient> Imaging Header Elements Template ID 1.2.840.10008.20.x4.x2 Name Imaging Header Elements Effective Date Version Label DICOM-yyyymmdd Status draft Description CDA Header Elements for imaging reports, including encounter, order, and study context Classification CDA Header Elements Relationships Invoked from Imaging Report Context sibling node Open/Closed Open Revision History DICOM-yyyymmdd: Initial version
General requirements for sections Section Text Template ID 1.2.840.10008.20.x4.x0 Name Section Text Effective Date (Date of Final Text adoption) Version Label DICOM-yyyymmdd Status Draft (will change to Active on Final Text adoption) Description This template specifies the common set of narrative block markup that may be invoked in a CDA imaging report section. Classification CDA Element Set Relationships Invoked by all sections Context Open/Closed Open Revision History DICOM-yyyymmdd: Initial version Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template Text text 1..1 ED Content[*] > content 0..* MAY ST * >@ @ID 1..1 SHALL XML ID [See ] Style >@ @styleCode 0..1 MAY XML IntRef[*] > linkHtml 0..* MAY ST >@ @href 1..1 SHALL ST (URL - XML IDREF) Graphic[*] > renderMultiMedia 0..* MAY >@ @referencedObject 1..1 SHALL XML IDREF Caption >> caption 0..1 MAY ST
Relationships Invoked by Findings section and its sub-sections, Clinical Information, and other sections Context sibling node Open/Closed open Revision History DICOM-yyyymmdd: Initial version Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template templateId 0..1 MAY II author 0..* MAY > assignedAuthor 1..1 SHALL AuthorID >> id 1.* SHALL II >> assignedPerson 1..1 AuthorName >>> name 1..1 SHALL PN >> 1..1 >>> 0..1 SHOULD ST >>> softwareName 0..1 SHOULD ST >> 0..1 MAY >>> name 0..1 SHOULD ON entry 0..* MAY > observation 1..1 SHALL entry 0..* MAY > observation 1..1 SHALL entry 0..* MAY > observationMedia 1..1 SHALL entry 0..* MAY Device
Name Medical (General) History Effective Date 2012-07 Version Label DICOM-yyyymmdd Status Active Description 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. Classification CDA Section Level Relationships Invoked by Section Level template Context Open/Closed Open Revision History From Consolidated CDA r1.1 DICOM-yyyymmdd: Addition of optional entries; C-CDA templateID retained Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template History section 1..1 SHALL > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..* SHALL II > code 1..1 SHALL CD SHALL (11329-0, LOINC, "History General") Title > title 1..1 SHALL ST Text > text 1..1 ED > 0..1 MAY
Text > text 0..1 SHALL ED Content[*] >> content 0..* SHALL ST [See ] * >>@ @ID 1..1 SHALL XML ID GuidelineRef >>> linkHtml 0..1 MAY ST GuidelineURI >>>@ @href 1..1 SHALL URI > entry 0..* SHOULD >> procedure 1..1 SHALL * >>@ @ID 1..1 SHALL XML ID [See ] >>@ @classCode 1..1 SHALL CS SHALL PROC >>@ @moodCode 1..1 SHALL CS SHALL PRP >>> code 1..1 SHALL CD When >>> effectiveTime 1..1 SHOULD IVL <TS> >>> text 1..1 SHALL ED Ref >>>> reference 1..1 SHALL URL (XML IDREF) #contentRef text/content Each documented recommendation SHALL be included as narrative in a content element, labeled with an XML ID (see). The content element NEED NOT be top level markup within the section/text element; it MAY be wrapped in another allowed narrative block markup, such as paragraph, list/item, or table/row/cell. If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element. Each recommendation SHOULD have a corresponding structured entry. entry/procedure and @ID The Recommendation section SHOULD include entries for recommended follow-up actions or procedures. Each entry/procedure SHALL include an XML ID attribute (not to be confused Recommended Follow-up
Revision History DICOM-yyyymmdd: 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 includes recommended XML ID, and uses DICOM-yyyymmdd SOP Instance subsidiary template. Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template Series[*] act 1..1 SHALL @ @classCode 1..1 SHALL CS SHALL ACT @ @moodCode 1..1 SHALL CS SHALL EVN * @ @ID 0..1 SHOULD XML ID [See ] > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..1 SHALL SeriesUID >@ @root 1..1 SHALL UID Series Instance UID (0020,000E) >@ @extension 0..0 SHALL NOT > code 1..1 SHALL CD SHALL (113015, DCM, "Series" >> qualifier 1..1 SHALL >>> name 1..1 SHALL CD SHALL (121139, DCM, "Modality") Modality >>> value 1..1 SHALL CD Modality (0008,0060) Description > text 0..1 MAY ED Time > effectiveTime 0..1 SHOULD TS Series Date (0008,0021) + Series Time (0008,0031) + Timezone Offset From UTC (0008,0201) > entryRelationship 1..* SHALL
Description 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. Classification CDA Entry Level Relationships Context Open/Closed open Revision History DICOM-yyyymmdd: 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 This derivation includes required XML ID; Purpose of Reference value set specified with DICOM CID 7003; directly incorporates descendant templates Purpose of Reference Observation, Referenced Frames, and Boundary Observation Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template observation 1..1 SHALL @ @classCode 1..1 SHALL CS SHALL DGIMG @ @moodCode 1..1 SHALL CS SHALL EVN * @ @ID 0..1 SHOULD XML ID [See ] > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..* SHALL II SOP Instance UID (0008,0018) > code 1..1 SHALL CD >@ @code 1..1 SHALL ST SOP Class UID (0008,0016) >@ @codeSystem 1..1 SHALL UID SHALL > text 0..1 SHOULD ED >@ @mediaType 1..1 SHALL ST SHALL >> reference 1..1 SHALL URL SOPInstance
C.4.4.1 Current Procedure Descriptions SR Instances using TID 2006 have a Current Procedure Descriptions section specified using TID 2007. Source data in that template is mapped into the CDA Procedure Description section. Table C.4-1 Current Procedure Description mapping from SR CDA Business Name DICOM SR ProcedureDescription: ProcedureTechnique: ProcedureCode Procedure Code Sequence (0008,1032) ProcedureDescription: ProcedureTechnique: EffectiveTime (111060, DCM, "Study Date") + (111061, DCM, "Study Time") ProcedureDescription: ProcedureTechnique: Modality (122142, DCM, "Acquisition Device Type"} ProcedureDescription: ProcedureTechnique: MethodCode ProcedureDescription: ProcedureTechnique: TargetSite (123014, DCM,"Target Region") ProcedureDescription: ProcedureTechnique: Laterality ProcedureDescription: ProcedureTechnique: Ref C.4.4.2 Radiation Exposure and Protection Information 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. Table C.4-2 CDA Radiation Exposure and Protection Information mapping from SR CDA Business Name DICOM SR RadiationExposure: IrradiationAuthorizingID RadiationExposure: IrradiationAuthorizingName (113850, DCM, "Irradiation Authorizing ") RadiationExposure: SOPInstance[doseReport] (113701, DCM, "X-Ray Radiation Dose Report") [from Current Procedure Description section] RadiationExposure: CodedObservation[pregnancy] (111532, DCM,"Pregnancy Status") RadiationExposure: (18785-6, LN, "Indications for Procedure")
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 (0008,1110) SQ ffffffff
Study Sequence %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 %enditem %endseq >> Series Instance UID (0020,000e) UI 0036 1.2.840.113619.2.62.994044785528.20060823223142485051 %enditem %endseq > Study Instance UID (0020,000d) UI 002e 1.2.840.113619.2.62.994044785528.114289542805 %enditem %endseq Completion Flag (0040,a491) CS 0008 COMPLETE Verification Flag (0040,a493) CS 0008 VERIFIED 1 Content Sequence (0040,a730) SQ ffffffff 1.1 %item 1.1 > Relationship Type (0040,a010) CS 0010 HAS CONCEPT MOD 1.1 > Value Type (0040,a040) CS 0004 CODE 1.1 > Concept Name Code Sequence (0040,a043) SQ ffffffff 1.1 %item