Template 2.16.840.1.113883.10.20.22.1.5 Diagnostic Imaging Report

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.5 - DiagnosticImagingReport
Id 2.16.840.1.113883.10.20.22.1.5
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑732
Version valid from 2012‑01‑12 status draft
Description A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.
Item DT Card Conf Desc Label
cda:ClinicalDocument
Descriptions for sections is under development in DICOM in cooperation with the RSNA reporting initiative
All sections defined in the DIR Section Type Codes table SHALL be top-level sections
A section element SHALL have a code element which SHALL contain a LOINC code or DCM code for sections which have no LOINC equivalent. This only applies to sections described inthe DIR Section Type Codes table
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 and the text content of linkHtml is the visible text of the hyperlink
If clinical statements are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text
If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
If the subject of a section is a fetus, the section SHALL contain a subject element containing a Fetus Subject Context (templateId 2.16.840.1.113883.10.20.6.2.3)
: If the author of a section is different from the author(s) listed in the Header, an author element SHALL be present containing Observer Context (templateId 2.16.840.1.113883.10.20.6.2.4)
conf-732
treetree cda:templateId
II 1..1 M conf‑9405
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8404
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.5
Schematron assert Role red error
Test //cda:ClinicalDocument/cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID.
Schematron assert Role red error
Test //cda:ClinicalDocument/cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
Schematron assert Role red error
Test string-length(//cda:ClinicalDocument/cda:id/@root)<65
Message
OIDs SHALL be no more than 64 characters in length.
treetree cda:code
1..1 M conf‑8408
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.32 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.9.32"
treetree cda:informant
NP conf‑8410
treetree cda:informationRecipient
0..* O The physician requesting the imaging procedure (ClincalDocument/participant[@typeCode=REF]/associatedEntity), if present, SHOULD also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report.
When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient MAY be absent. The intendedRecipient MAY also be the health chart of the patient, in which case the receivedOrganization SHALL be the scoping organization of that chart.
conf‑8411
treetree cda:participant
0..1 O conf‑8414
treeblank treetree cda:assignedEntity
_cda:assignedPerson
1..1 M conf‑8415
Schematron assert Role red error
Test true()
Message
If participant is present, the assignedEntity/assignedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
treeblank treeblank treetree cda:name
PN 1..1 M conf‑9406
Schematron assert Role red error
Test cda:given|cda:family or (count(*)=0 and string-length(.)!=0)
Message
The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1)
treetree cda:documentationOf
1..1 M conf‑8416
treeblank treetree cda:serviceEvent
1..1 M conf‑8431
treeblank treeblank treetree @classCode
1..1 F ACT
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.1 with overridden cardinality 1 .. 1 mandatory
treeblank treeblank treetree cda:id
II 0..* R conf‑8418
treeblank treeblank treetree cda:code
CE 1..1 M The value of serviceEvent/code SHALL NOT conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor SHALL be used on serviceEvent/code. conf‑8419
treetree cda:relatedDocument
0..1 O When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode SHALL be XFRM, and relatedDocument/parentDocument/id SHALL contain the SOP Instance UID of the original DICOM SR document. conf‑8432
Schematron assert Role red error
Test cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
The relatedDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID
Schematron assert Role red error
Test cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
Schematron assert Role red error
Test string-length(cda:id/@root)<65
Message
OIDs SHALL be no more than 64 characters in length
treeblank treetree cda:componentOf
0..1 O conf‑8434
treeblank treeblank treetree cda:encompassingEncounter
1..1 M conf‑8449
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.2 with overridden cardinality 1 .. 1 mandatory
treeblank treeblank treeblank treetree cda:id
II 1..* M In the case of transformed DICOM SR documents, an appropriate null flavor MAY be used if the id is unavailable. conf‑8435
treeblank treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8437
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treeblank treeblank treetree cda:responsibleParty
0..1 O conf‑8438
treeblank treeblank treeblank treeblank treetree cda:assignedEntity
1..1 M conf‑9407
Schematron assert Role red error
Test count(cda:assignedPerson | cda:representedOrganization)<2
Message
SHOULD contain zero or one [0..1] assignedPerson OR SHOULD contain zero or one [0..1] representedOrganization
Schematron assert Role red error
Test //cda:component[1]/cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1'
Message
The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, SHALL be the first section in the document Body
Schematron assert Role red error
Test //cda:component/cda:structuredBody//cda:section[not(cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1') and(cda:title)]
Message
With the exception of the DICOM Object Catalog (templateId 2.16.840.1.113883.10.20.6.1.1), all sections within the Diagnostic Imaging Report content SHOULD contain a title element
Schematron assert Role red error
Test //cda:section/cda:code[@codeSystem='1.2.840.10008.2.16.4 ' or @codeSystem='2.16.840.1.113883.6.1']
Message
The section/code SHOULD be selected from LOINC® or DICOM for sections not listed in the DIR Section Type Codes table
Schematron assert Role red error
Test //cda:component/cda:structuredBody//cda:section[not(cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1') and ((//cda:component) or (//cda:text))]
Message
Apart from the DICOM Object Catalog (templateId 2.16.840.1.113883.10.20.6.1.1), all other instances of section SHALL contain at least one text element or one or more component elements
Schematron assert Role red error
Test not(//cda:text[count(*)=0 and string-length()=0]) and not(//cda:component[count(*)=0])
Message
All text or component elements SHALL contain content. text elements SHALL contain PCDATA or child elements, and component elements SHALL contain child elements