A.6.2 Transcoded HL7 CDA Release 2 "Diagnostic Imaging Report"
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<!-- from DICOM TID 1210 "Equivalent Meaning(s) of Concept Name"
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<title>Chest X-Ray, PA and LAT View</title>
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<!-- CDA DIR effective time usually will be different from SR study date
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<!-- Unique identifier for root: {root}.10 = patient ID list added based on
organizational policy (not present in SR sample document because root is
not specified by DICOM. DICOM Patient ID (0010,0020) value inserted into
extension -->
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<patient>
<name>
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<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>Richard</given>
<family>Blitz</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<custodian>
<!-- custodian values have been added based on organizational policy (in
this case they are not mapped from the SR sample document)-->
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5" />
<name>World University Hospital</name>
<telecom nullFlavor="NI" />
<addr nullFlavor="NI" />
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- legal authenticator present in sample, document is VERIFIED -->
<legalAuthenticator>
<time value="20060827141500" />
<!-- verification date time (0040,A030)-->
<signatureCode code="S" />
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<assignedPerson>
<name>
<given>Richard</given>
<family>Blitz</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
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<!-- Mapped from Referring physicians name (0008,0090) SR sample document -->
<participant typeCode="REF">
<associatedEntity classCode="PROV">
<id nullFlavor="NI" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<associatedPerson>
<name>
<given>John</given>
<family>Smith</family>
<suffix>MD</suffix>
</name>
</associatedPerson>
</associatedEntity>
</participant>
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<order>
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<!-- {root}.27 of accession number added based on organizational policy (not
present in SR sample document because root is not specified by DICOM).
Accession number value used in extension -->
<id extension="123452" root="1.2.840.113619.2.62.994044785528.28" />
<!-- {root}.28 of filler order number added based on organizational policy (not
present in SR sample document because root is not specified by DICOM).
Filler number value used in extension -->
<id extension="123451" root="1.2.840.113619.2.62.994044785528.29" />
<!-- {root}.29 of placer order number added based on organizational policy (not
present in SR sample document because root is not specified by DICOM).
Placer number value used in extension -->
</order>
</inFulfillmentOf>
<documentationOf>
<serviceEvent classCode="ACT">
<id root="1.2.840.113619.2.62.994044785528.114289542805" />
<!-- study instance UID -->
<code nullFlavor="NI" />
<effectiveTime value="20060823222400" />
</serviceEvent>
</documentationOf>
<!-- transformation of a DICOM SR -->
<relatedDocument typeCode="XFRM">
<parentDocument>
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<!-- SOP Instance UID (0008,0018) of SR sample document-->
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DICOM Object Catalog Section
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<section classCode="DOCSECT" moodCode="EVN">
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<entry>
<!--
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Study
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<act classCode="ACT" moodCode="EVN">
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</code>
<!--
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SopInstance UID
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<!-- Reference to SR Document -->
<entryRelationship typeCode="COMP">
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<!--reference to image 1 (PA) -->
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<!--
*****************************************************************
Series (CR Images)
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<!--
*****************************************************************
SopInstance UID
*****************************************************************
-->
<!-- 2 References (chest PA and LAT) -->
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<code code="1.2.840.10008.5.1.4.1.1.1"
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displayName="Computed Radiography Image Storage"></code>
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<!--reference to image 1 (PA) -->
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<!--reference to image 2 (LAT) -->
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<!--
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End of DICOM Object Catalog Section
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<component>
<!--
**********************************************************************
Reason for study Section
**********************************************************************
The original DICOM SR document that is mapped does not contain a
"Indications for Procedure" section. The attribute value "Reason
for the Requested Procedure" (0040,1002) within the Referenced
Request Sequence (0040,A370) of the SR header has been mapped under
the assumption that the header attribute value has been displayed to
and included by the legal authenticator.
-->
<section>
<code code="121109" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="Indications for Procedure" />
<title>Indications for Procedure</title>
<text>Suspected lung tumor</text>
</section>
<!--
**********************************************************************
Reason for study Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
History Section
**********************************************************************
-->
<section>
<code code="121060" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="History" />
<title>History</title>
<text>
<paragraph>
<caption>History</caption>
<content ID="Fndng1">Sore throat.</content>
</paragraph>
</text>
<entry>
<!-- History report element (TEXT) -->
<observation classCode="OBS" moodCode="EVN">
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<code code="121060" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="History" />
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<reference value="#Fndng1" />
</value>
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</section>
<!--
**********************************************************************
End of History Section
**********************************************************************
-->
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<!--
**********************************************************************
Findings Section
**********************************************************************
-->
<section>
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codeSystemName="DCM" displayName="Findings" />
<title>Findings</title>
<text>
<paragraph>
<caption>Finding</caption>
<content ID="Fndng2">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.</content>
</paragraph>
<paragraph>
<caption>Diameter</caption>
<content ID="Diam2">45mm</content>
</paragraph>
<paragraph>
<caption>Source of Measurement</caption>
<content ID="SrceOfMeas2">
<linkHtml href="http://www.example.org/wado?requestType=WADO
&studyUID=1.2.840.113619.2.62.994044785528.114289542805
&seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
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&contentType=application/dicom">
Chest_PA</linkHtml>
</content>
</paragraph>
</text>
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<!-- Text Observation -->
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<value xsi:type="ED">
<reference value="#Fndng2" />
</value>
<!-- inferred from measurement -->
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codeSystemName="SNOMED" displayName="Nodule size">
<originalText>
<reference value="#Diam2" />
</originalText>
</code>
<!-- no DICOM attribute <statusCode code="completed"/> -->
<effectiveTime value="20060823223912" />
<value xsi:type="PQ" value="45" unit="mm" />
<!-- inferred from image -->
<entryRelationship typeCode="SUBJ">
<observation classCode="DGIMG" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.8" />
<!-- (0008,1155) Referenced SOP Instance UID-->
<id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3" />
<!-- (0008,1150) Referenced SOP Class UID -->
<code code="1.2.840.10008.5.1.4.1.1.1"
codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
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<text mediaType="application/dicom">
<!--reference to CR DICOM image (PA view) -->
<reference value="http://www.example.org/wado?requestType=WADO
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<effectiveTime value="20060823223232" />
<!-- Purpose of Reference -->
<entryRelationship typeCode="RSON">
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<code code="ASSERTION"
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<value xsi:type="CD" code="121112"
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codeSystemName="DCM"
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<originalText>
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</originalText>
</value>
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</observation>
</entry>
</section>
<!--
**********************************************************************
End of Findings Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
Impressions Section
**********************************************************************
-->
<section>
<code code="121072" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="Impressions" />
<title>Impressions</title>
<text>
<paragraph>
<caption>Impression</caption>
<content ID="Fndng3">No acute cardiopulmonary process. Round
density in left superior hilus, further evaluation with CT is
recommended as underlying malignancy is not excluded.</content>
</paragraph>
</text>
<entry>
<!-- Impression report element (TEXT) -->
<observation classCode="OBS" moodCode="EVN">
<!-- Text Observation -->
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<!--
**********************************************************************
End of Impressions Section
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