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pending Template  Diagnostic Imaging Report

Template 2.16.840.1.113883.10.20.22.1.5 - DiagnosticImagingReport
Id 2.16.840.1.113883.10.20.22.1.5
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 6 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.6.2.1 Containment PhysicianReadingStudyPerformer DYNAMIC
2.16.840.1.113883.10.20.6.2.2 Containment PhysicianofRecordParticipant DYNAMIC
2.16.840.1.113883.10.20.6.2.5 Containment ProcedureContext DYNAMIC
2.16.840.1.113883.10.20.6.2.3 Containment FetusSubjectContext DYNAMIC
2.16.840.1.113883.10.20.6.1.2 Containment FindingsSectionDIR DYNAMIC
2.16.840.1.113883.10.20.6.1.1 Containment DICOMObjectCatalogSection-DCM121181 DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID.

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))+

OIDs SHALL be no more than 64 characters in length.

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

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

The section/code SHOULD be selected from LOINC® or DICOM for sections not listed in the DIR Section Type Codes table

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 that have no LOINC equivalent. This only applies to sections described in the DIR Section Type Codes table

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

All text or component elements SHALL contain content. Text elements SHALL contain PCDATA or child elements, and component elements SHALL contain child elements

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
(DiagnosticImagingReport)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8404) such that it conf‑8404
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.5
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14833). conf‑14833
treetree cda:informant
SHALL NOT contain [0..0] informant (CONF:8410). conf‑8410
  Schematron assert role red error
  test not(cda:informant)
  Message SHALL NOT contain [0..0] informant (CONF:8410).
treetree cda:informationRecipient
0 .. * MAY contain zero or more [0..*] informationRecipient (CONF:8411).

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 MAY contain zero or one [0..1] participant (CONF:8414) such that it conf‑8414
treeblank treetree cda:assignedPerson
1 .. 1 M SHALL contain exactly one [1..1] assignedPerson (CONF:8415). conf‑8415
  Schematron assert role red error
  test cda:assignedEntity/cda:assignedPerson
  Message SHALL contain exactly one [1..1] assignedPerson (CONF:8415).
treeblank treeblank treetree cda:name
1 .. 1 M This assignedPerson SHALL contain exactly one [1..1] name (CONF:9406).

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)
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 SHALL contain exactly one [1..1] documentationOf (CONF:8416) such that it conf‑8416
treeblank treetree cda:serviceEvent
1 .. 1 M conf‑8431
treeblank treeblank treetree @classCode
1 .. 1 F ACT
  Contains 2.16.840.1.113883.10.20.6.2.1 Physician Reading Study Performer (DYNAMIC)
treeblank treeblank treetree cda:id
0 .. * R This serviceEvent SHOULD contain zero or more [0..*] id (CONF:8418). conf‑8418
treeblank treeblank treetree cda:code
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] code (CONF:8419). conf‑8419
treetree cda:relatedDocument
0 .. 1 MAY contain zero or one [0..1] relatedDocument (CONF:8432) such that it

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
treeblank treetree cda:id
1 .. 1 M SHALL contain exactly one [1..1] id (CONF:10030).

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))+

OIDs SHALL be no more than 64 characters in length
conf‑10030
  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 SHALL contain exactly one [1..1] id (CONF:10030).
treeblank treeblank treetree cda:componentOf
0 .. 1 This id MAY contain zero or one [0..1] componentOf (CONF:8434). conf‑8434
treeblank treeblank treeblank treetree cda:encompassingEncounter
1 .. 1 M conf‑8449
  Contains 2.16.840.1.113883.10.20.6.2.2 Physician of Record Participant (DYNAMIC)
treeblank treeblank treeblank treeblank treetree cda:id
1 .. * M This encompassingEncounter SHALL contain at least one [1..*] id (CONF:8435).

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 treeblank treetree cda:effectiveTime
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8437).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑8437
  Schematron assert role red error
  test not(cda:relatedDocument/cda:id/cda:componentOf) or string-length(cda:relatedDocument/cda:id/cda:componentOf/cda:encompassingEncounter/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treeblank treeblank treeblank treeblank treetree cda:responsibleParty
0 .. 1 This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8438). conf‑8438
treeblank treeblank treeblank treeblank treeblank treetree cda:assignedEntity
1 .. 1 M The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:9407).

SHOULD contain zero or one [0..1] assignedPerson OR SHOULD contain zero or one [0..1] representedOrganization
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: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
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:14907).

A Diagnostic Imaging Report can have either a structuredBody or a nonXMLBody.

If structuredBody, the component/structuredBody SHALL conform to the section constraints below.
conf‑14907
  Schematron assert role red error
  test count(cda:component/cda:structuredBody | cda:component/cda:nonXMLBody) =1
  Message A Diagnostic Imaging Report can have either a structuredBody or a nonXMLBody.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treetree cda:nonXMLBody
(DiagnosticImagingReport)
treeblank treetree cda:structuredBody
: 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) (DiagnosticImagingReport)
treeblank treeblank treetree cda:component
where
[cda:act [cda:templateId/@root='2.16.840.1.113883.10.20.6.2.5']]
0 .. * 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 conf‑9417
  Contains 2.16.840.1.113883.10.20.6.2.5 Procedure Context (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.6.2.3']]
0 .. * 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) conf‑9419
  Contains 2.16.840.1.113883.10.20.6.2.3 Fetus Subject Context (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.6.1.2']]
1 .. 1 M conf‑9484
  Contains 2.16.840.1.113883.10.20.6.1.2 Findings Section (DIR) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1']]
0 .. 1 R conf‑15141
  Contains 2.16.840.1.113883.10.20.6.1.1 DICOM Object Catalog Section - DCM 121181 (DYNAMIC)
  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/@code
1 .. 1 M SHALL contain exactly one [1..1] code/@code, which SHALL be selected from ValueSet DIRDocumentTypeCodes 2.16.840.1.113883.11.20.9.32 DYNAMIC (CONF:8408). conf‑8408
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.32 DIRDocumentTypeCodes (DYNAMIC)
  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