7 Document-level Templates
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# 7 Document-level Templates

Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and sections by referring to templates, and constraints on the vocabulary used in those templates.

## 7.1 Imaging Report

Template ID | 1.2.840.10008.9.1
Name | Imaging Report
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | This CDA Imaging Report document template defines the report content and technical constraints for top level elements, attributes, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or therapeutic radiology, cardiology, or other imaging reports. The body of an Imaging Report may contain five main imaging report sections: Clinical information (optionally); Current imaging procedure description; Comparison studies (optionally); Findings (optionally); Impression; plus potentially an Addendum(s) The report templates sponsored by the RSNA Radiology Reporting Initiative (http://www.radreport.org) adhere to this general section outline.
Classification | CDA Document Level
Relationships |
Context | parent node
Open/Closed | Open
Revision History | DICOM-20150324: Initial version

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
Imaging​Report |  | Clinical​Document |  |  |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.1 |
Doc​Type | > | code | 1..1 | SHALL | CD | SHALL CWE noNull | ValueSet LOINC Imaging Document Codes 1.3.6.1.4.1.12009.10.2.5 |
| > |  | 1..1 | SHALL |  |  |  | 8.1 General Header 1.2.840.10008.9.20
| > |  | 1..1 | SHALL |  |  |  | 8.2 Imaging Header 1.2.840.10008.9.21
| > |  | 0..1 | MAY |  |  |  | 8.3 Parent Document 1.2.840.10008.9.22
| > | component | 1..1 | SHALL |  |  |  |
| >> | structured​Body | 1..1 | SHALL |  |  |  |
| >>> | component | 0..1 | MAY |  |  |  |
Clinical​Information | >>>> | section |  |  |  |  |  | 9.2 Clinical Information 1.2.840.10008.9.2
| >>> | component | 1..1 | SHALL |  |  |  |
Procedure​Description | >>>> | section |  |  |  |  |  | 9.3 Imaging Procedure Description 1.2.840.10008.9.3
| >>> | component | 0..1 | MAY |  |  |  |
Comparison​Study | >>>> | section |  |  |  |  |  | 9.4 Comparison Study 1.2.840.10008.9.4
| >>> | component | 0..1 | MAY |  |  |  |
Findings | >>>> | section |  |  |  |  |  | 9.5 Findings 2.16.840.1.113883.​10.20.6.1.2
| >>> | component | 1..1 | SHALL |  |  |  |
Impression | >>>> | section |  |  |  |  |  | 9.6 Impression 1.2.840.10008.9.5
| >>> | component | 0..* | COND |  |  |  |
Addendum[*] | >>>> | section |  |  |  |  |  | 9.7 Addendum 1.2.840.10008.9.6

### 7.1.1 clinicalDocument/code

Most of the codes in Value Set LOINC Imaging Document Codes are pre-coordinated with the imaging modality, body part examined, and/or specific imaging method. When pre-coordinated codes are used, any coded values elsewhere in the document describing the modality, body part, etc., must be consistent with the document type code. Local codes used for report types may be included as a translation element in the code.

### Note

Use of Value Set LOINC Imaging Document Codes is harmonized with HL7 Consolidated CDA Templates for Clinical Notes, Release 2. DICOM CID 7001 “Diagnostic Imaging Report Headings”, used in TID 2000 “Basic Diagnostic Imaging Report”, is a subset of the LOINC Imaging Document Codes.

Example 7.1.1-1. clinicalDocument/code example with translation element for local code

    <code code="18748-4"
            displayName="Diagnostic Imaging Report"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" >
        <translation code="XRPEDS"
            displayName="Pediatric Radiography Report"
            codeSystem="2.16.840.1.123456.78.9" />
    </code>

### 7.1.2 Addendum

COND: If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator element (i.e., was signed), the component/structuredBody SHALL contain at least one 9.7 Addendum.

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6 Conformance | Home | 7.2 Imaging Addendum Report