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Template ID |
2.16.840.1.113883.10.20.6.1.2 |
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Name |
Findings |
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Effective Date |
2015/03/24 |
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Version Label |
DICOM-20150324 |
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Status |
Active |
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Description |
Records clinically significant observations confirmed or discovered during the procedure. |
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Classification |
CDA Section Level |
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Relationships |
Included in 7.1 Imaging Report |
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Context |
parent node |
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Open/Closed |
Open |
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Revision History |
From Consolidated CDA r1.1 DICOM-20150324: Added optional subsections and entries |
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Findings |
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2.16.840.1.113883.10.20.6.1.2 |
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9.1.1 Section Text 1.2.840.10008.9.19 |
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FetusFindings[*] |
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9.8.8 Fetus Findings 1.2.840.10008.9.9 |
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9.8.9 Labeled Subsection 1.2.840.10008.9.10 |
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9.1.2 General Section Entries 1.2.840.10008.9.23 |
If entries are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text.
The narrative text associated with an actionable finding SHOULD be highlighted using styleCode Bold. See Section 9.1.1.1.
Actionable findings that require a specific follow-up action or procedure SHOULD be referenced from a recommendation in the 9.8.11 Recommendation section.
Communication of actionable findings SHOULD be documented in the 9.8.10 Communication of Actionable Findings section.
Example 9.5.1-1. Findings section example
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.1.2"/>
<id root="1.2.840.10213.2.62.941494044785528.114289542452452805"/>
<code code="59776-5" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Procedure Findings"/>
<title>Findings</title>
<text>
<paragraph>
<caption>Finding</caption>
<content ID="Fndng2">The cardiomediastinum is... </content>
</paragraph>
<paragraph>
<caption>Diameter</caption>
<content ID="Diam2">45mm</content>
</paragraph>
...
</text>
<entry>
<templateId root="2.16.840.1.113883.10.20.6.2.12"/>
...
</entry>
<!-- see examples for other sections/entries -->
</section>