|
Template ID |
1.2.840.10008.9.2 |
|
Name |
Clinical Information |
|
Effective Date |
2015/03/24 |
|
Version Label |
DICOM-20150324 |
|
Status |
Active |
|
Description |
Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc. |
|
Classification |
CDA Section Level |
|
Relationships |
Included in 7.1 Imaging Report |
|
Context |
parent node |
|
Open/Closed |
Open |
|
Revision History |
DICOM-20150324: Initial version |
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Business Name |
Nest Level |
Element/Attribute |
Card |
Elem/Attr Conf |
Data Type |
Value Conf |
Value |
Subsidiary Template |
|---|---|---|---|---|---|---|---|---|
|
ClinicalInformation |
section |
1..1 |
SHALL |
|||||
|
> |
templateId |
1..1 |
SHALL |
II |
||||
|
>@ |
@root |
1..1 |
SHALL |
UID |
SHALL |
1.2.840.10008.9.2 |
||
|
> |
id |
1..1 |
SHALL |
II |
||||
|
> |
code |
1..1 |
SHALL |
CD |
SHALL |
|||
|
Title |
> |
title |
1..1 |
SHALL |
ST |
|||
|
Text |
> |
text |
1..1 |
COND |
ED |
9.1.1 Section Text 1.2.840.10008.9.19 |
||
|
> |
component |
0..1 |
MAY |
|||||
|
Request |
>> |
section |
1..1 |
SHALL |
9.8.1 Request 1.2.840.10008.9.7 |
|||
|
> |
component |
0..1 |
MAY |
|||||
|
ProcedureIndications |
>> |
section |
1..1 |
SHALL |
9.8.2 Procedure Indications 1.2.840.10008.9.22 |
|||
|
> |
component |
0..1 |
MAY |
|||||
|
History |
>> |
section |
1..1 |
SHALL |
9.8.3 Medical (General) History 2.16.840.1.113883.10.20.22.2.39 |
|||
|
> |
0..1 |
MAY |
9.1.2 General Section Entries 1.2.840.10008.9.23 |
Example 9.2-1. Clinical Information section example
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="1.2.840.10008.9.2"/>
<id root="1.2.840.10213.2.62.994044785528.114289542805"/>
<code code="55752-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Clinical Information"/>
<title>Clinical Information</title>
<text>The patient was referred for evaluation of suspected pulmonary embolism.</text>
<!---see examples for other sections/entries -->
</section>