DICOM PS3.20 2016b - Imaging Reports using HL7 Clinical Document Architecture

8 Header Content Templates
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# 8 Header Content Templates

## 8.1 General Header

Template ID | 1.2.840.10008.9.20
Name | General Header Elements
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | CDA Header Elements for all documents, including primary participations
Classification | CDA Header Elements
Relationships | Included in all document level templates
Context | sibling 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
--- | --- | --- | --- | --- | --- | --- | --- | ---
|  | template​Id | 1..1 | SHALL | II |  |  |
| @ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.20 |
Content​Template |  | template​Id | 0..* | MAY | II |  |  |
|  | type​Id | 1..1 | SHALL | II |  |  |
| @ | @root | 1..1 | SHALL | UID | SHALL | 2.16.840.1.113883.​1.3 |
| @ | @extension | 1..1 | SHALL | ST | SHALL | POCD_HD000040 |
|  | id | 1..1 | SHALL | II |  |  |
Title |  | title | 1..1 | SHALL | ST |  |  |
Creation​Time |  | effective​Time | 1..1 | SHALL | TS |  |  |
Confidentiality |  | confidentiality​Code | 1..1 | SHALL | CE | SHALL CWE | ValueSet x_BasicConfidentialityKind Value Set 2.16.840.1.113883.11.16926 |
Language​Code |  | language​Code | 1..1 | SHALL | CS | SHALL CNE | ValueSet CID 5000 “Languages” |
Set​Id |  | set​Id | 0..1 | MAY | II |  |  |
Version​Number |  | version​Number | 1..1 | COND | INT |  |  |
Patient[*] |  | record​Target | 1..* | SHALL |  |  |  |
| > | patient​Role | 1..1 | SHALL |  |  |  |
| >> | id | 1..* | SHALL | II |  |  |
IDIssuer | >>@ | root | 1..1 | SHALL | UID |  | Issuer of Patient ID Qualifiers Sequence (0010,0024) > Universal Entity ID (0040,0032) Patient ID List PID-3.4.2 |
ID | >>@ | extension | 1..1 | SHALL | ST |  | Patient ID (0010,0020) Patient ID List PID-3.1 |
Addr | >> | addr | 1..* | SHALL | AD |  |  |
Tele | >> | telecom | 1..* | SHALL | TEL |  |  |
| >> | patient | 1..1 | SHALL |  |  |  |
Name | >>> | name | 1..1 | SHALL | PN |  | Patient's Name (0010,0010) Patient Name PID-5 |
Gender | >>> | administrative​Gender​Code | 1..1 | SHALL | CE | SHALL CNE | ValueSet AdministrativeGender Value Set 2.16.840.1.113883.11.1 Patient's Sex (0010,0040); [Map value "O" to nullFlavor UNK] Administrative Sex PID-3.8 |
Birth​Time | >>> | birth​Time | 1..1 | SHALL | TS |  | Patient's Birth Date (0010,0030) + Patient's Birth Time (0010,0032) Date/Time of Birth PID-7 |
| >> | provider​Organization | 0..1 | MAY |  |  |  |
Provider​Org​Name | >>> | name | 1..* | SHALL | ON |  | Issuer of Patient ID (0010,0021) |
Provider​Org​Tel | >>> | telecom | 0..* | SHOULD | TEL |  |  |
Provider​Org​Addr | >>> | addr | 0..* | SHOULD | AD |  |  |
|  | legal​Authenticator | 0..1 | MAY |  |  |  |
Signing​Time | > | time | 1..1 | SHALL | TS |  |  |
| > | signature​Code | 1..1 | SHALL | CS | SHALL | S |
| > | assigned​Entity | 1..1 | SHALL |  |  |  |
Signer​ID | >> | id | 1.* | SHALL | II |  |  |
Signer​Addr | >> | addr | 1.* | SHALL | AD |  |  |
Signer​Tel | >> | telecom | 1..* | SHALL | TEL |  |  |
| >> | assigned​Person | 1..1 | SHALL |  |  |  |
Signer​Name | >>> | name | 1..1 | SHALL | PN |  |  |
Signature​Block | > | sdtc:signatureText | 0..1 | MAY | ED |  |  |
Author[*] |  | author | 1..* | SHALL |  |  |  |
Authoring​Time | > | time | 1..1 | SHALL | TS |  |  |
| > | assigned​Author | 1..1 | SHALL |  |  |  |
| >> | id | 1.* | SHALL | II |  |  |
Addr | >> | addr | 1.* | SHALL | AD |  |  |
Tel | >> | telecom | 1..* | SHALL | TEL |  |  |
| >> | assigned​Person | 1..1 | SHALL |  |  |  |
Name | >>> | name | 1..1 | SHALL | PN |  |  |
Recipient[*] |  | information​Recipient | 0..* | MAY |  |  |  |
| > | intended​Recipient | 1..1 | SHALL |  |  |  |
| >@ | @classCode | 1..1 | SHALL | CS | SHALL | ASSIGNED |
Addr | >> | addr | 0.* | MAY | AD |  |  |
Tel | >> | telecom | 0..* | MAY | TEL |  |  |
| >> | information​Recipient | 0..1 | MAY |  |  |  |
Name | >>> | name | 1..1 | SHALL | PN |  |  |
| >> | received​Organization | 0..1 | MAY |  |  |  |
Org | >>> | name | 1..1 | SHALL | ON |  |  |
|  | custodian | 1..1 | SHALL |  |  |  |
| > | assigned​Custodian | 1..1 | SHALL |  |  |  |
| >> | represented​Custodian​Organization | 1..1 | SHALL |  |  |  |
Custodian​Org​ID | >>> | id | 1.* | SHALL | II |  |  |
Custodian​Org​Name | >>> | name | 1..1 | SHALL | ON |  |  |
Custodian​Org​Addr | >>> | addr | 1..1 | SHALL | AD |  |  |
Custodian​Org​Tel | >>> | telecom | 1..1 | SHALL | TEL |  |  |

Note that there is no business name associated with this template. Rather, this template is an editorial convenience for template specification, and the Business Names for the elements of this template are logically part of the business name scope of the invoking template.

### 8.1.1 templateId - contentTemplate

This templateId may be used to identify the template(s) used to generate/constrain the content of the report. This element is in addition to the templateId of the document level template, and typically represents clinical sub-specialty requirements. See Section 5.1.1 on the structure and use of the templateId.

### Note

The IHE MRRT profile defines a "dcterms.identifier" that may be used for this templateId.

### 8.1.2 title

The title may include the title of the report template used.

### Note

The IHE MRRT profile defines a "dcterms.title" that may be used in this element.

### 8.1.3 effectiveTime

The effectiveTime signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not represented in CDA.

### 8.1.4 setID and versionNumber

The setID and versionNumber elements may be used by the document creation system to manage document revisions, in accordance with the CDA specification sections 4.2.1.7 and 4.2.1.8.

COND: If and only if the setID element is present, the versionNumber element SHALL be present.

### 8.1.5 recordTarget/patientRole

The recordTarget records the patient whose health information is described by the clinical document; it must contain at least one patientRole element.

Multiple recordTarget elements should be used only in the case of conjoined twins/triplets who are the subject of a single imaging procedure, or for special cases (e.g., pre-natal surgery, where a medical record has been established for the fetus).

Example 8.1.5-1. Header example

    <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
    <!-- DICOM Imaging Report Template -->
    <templateId root="1.2.840.10008.9.1"/>
    <!-- General Header Template -->
    <templateId root="1.2.840.10008.9.20"/>
    <id extension="999021" root="2.16.840.1.113883.19"/>
    <code codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC" code="18748-4"
        displayName="Diagnostic Imaging Report"/>
    <title>Radiology Report</title>
    <effectiveTime value="20150329171504+0500"/>
    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
    <languageCode code="en-US" codeSystem="2.16.840.1.113883.6.121"/>
    <setId extension="111199021" root="2.16.840.1.113883.19"/>
    <versionNumber value="1"/>

### 8.1.6 legalAuthenticator

The legalAuthenticator identifies the single person legally responsible for the correctness of the content of the document and SHALL be present if the document has been legally authenticated. In the context of an imaging report, this means the radiologist, cardiologist, or other professional who signed or validated the report.

### Note

Per the CDA Standard, the legal authenticator, if present, must be a person, and the authentication applies to the human-readable narrative in section/text and any renderMultiMedia referenced content. Structured entries and external images referenced through linkHtml are not attested by the legal authentication.

Based on local practice, clinical documents may be released before legal authentication. This implies that a clinical document that does not contain this element has not been legally authenticated.

The legalAuthenticator SHALL contain exactly one [1..1] time representing the time of signature.

The legalAuthenticator MAY contain zero or one [0..1] sdtc:signatureText extension element. This provides a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act. The element is described in the HL7 CDA Digital Signature Standard.

Example 8.1.6-1. legalAuthenticator example

    <legalAuthenticator>
        <time value="20050329224411+0500"/>
        <signatureCode code="S"/>
        <assignedEntity>
            <id extension="KP00017" root="2.16.840.1.113883.19"/>
            <addr>
                <streetAddressLine>21 North Ave.</streetAddressLine>
                <city>Burlington</city>
                <state>MA</state>
                <postalCode>02368</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:(555) 555-1003"/>
            <assignedPerson>
                <name>
                    <given>Henry</given>
                    <family>Seven</family>
                </name>
            </assignedPerson>
        </assignedEntity>
    </legalAuthenticator>

### 8.1.7 recordTarget/patientRole/Patient/birthTime

Patient birthTime SHALL be precise to year, SHOULD be precise to day.

Example 8.1.7-1. recordTarget example

    <recordTarget>
        <patientRole>
            <id extension="12345" root="2.16.840.1.113883.19"/>
            <!-Example ID using fake assigning authority OID. ->
            <id extension="111-00-1234" root="2.16.840.1.118975.4.1"/>
            <!-Fake Social Security Number using the actual SSN OID. ->
            <addr use="HP">
                <!-HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 ->
                <streetAddressLine>17 Daws Rd.</streetAddressLine>
                <city>Blue Bell</city>
                <state>MA</state>
                <postalCode>02368</postalCode>
                <country>US</country>
                <!-US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 ->
            </addr>
            <telecom value="tel:(781) 555-1212" use="HP"/>
            <!-HP is "primary home" from AddressUse 2.16.840.1.113883.5.1119 ->
            <patient>
                <name use="L">
                    <!-L is "Legal" from EntityNameUse 2.16.840.1.113883.5.45 ->
                    <prefix>Mr.</prefix>
                    <given>Adam</given>
                    <given qualifier="CL">Frankie</given>
                    <!-CL is "Call me" from EntityNamePartQualifier 2.16.840.1.113883.5.43 ->
                    <family>Everyman</family>
                </name>
                <administrativeGenderCode code="M"
                    codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
                <birthTime value="19541125"/>
            </patient>
            <providerOrganization>
                <id root="2.16.840.1.113883.19"/>
                <name>Good Health Clinic</name>
                <telecom use="WP" value="tel:(781) 555-1212"/>
                <addr>
                    <streetAddressLine>21 North Ave</streetAddressLine>
                    <city>Burlington</city>
                    <state>MA</state>
                    <postalCode>02368</postalCode>
                    <country>US</country>
                </addr>
            </providerOrganization>
        </patientRole>
    </recordTarget>

### 8.1.8 author/assignedAuthor

The author element represents the creator of the clinical document. This template restricts the author to be a person.

Such author SHALL contain exactly one [1..1] time representing the start time of the author's participation in the creation of the content of the clinical document.

Example 8.1.8-1. Person author example

    <author>
        <time value="20050329224411+0500"/>
        <assignedAuthor>
            <id extension="KP00017" root="2.16.840.1.113883.19.5"/>
            <addr>
                <streetAddressLine>21 North Ave.</streetAddressLine>
                <city>Burlington</city>
                <state>MA</state>
                <postalCode>02368</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:(555) 555-1003"/>
            <assignedPerson>
                <name>
                    <given>Henry</given>
                    <family>Seven</family>
                </name>
            </assignedPerson>
        </assignedAuthor>
    </author>

### 8.1.9 InformationRecipient/intendedRecipient

The informationRecipient participation elements record the intended recipients of the information at the time the document is created. An intended recipient may be a person (an informationRecipient entity), with or without an organization affiliation (receivedOrganization scoping entity), or simply an organization. If an organization, the document is expected to be incorporated into an information system of that organization (e.g., the electronic medical record for the patient).

Example 8.1.9-1. informationRecipient example

    <informationRecipient>
        <intendedRecipient classCode="ASSIGNED">
            <informationRecipient>
                <name>
                    <given>Henry</given>
                    <family>Seven</family>
                </name>
            </informationRecipient>
            <receivedOrganization>
                <name>Good Health Clinic</name>
            </receivedOrganization>
        </intendedRecipient>
    </informationRecipient>

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DICOM PS3.20 2016b - Imaging Reports using HL7 Clinical Document Architecture