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

9.8.8 Fetus Findings
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### 9.8.8 Fetus Findings

Template ID | 1.2.840.10008.9.9
Name | Fetus Findings
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | Records observations related to a fetus confirmed or discovered during an imaging procedure.
Classification | CDA Section Level
Relationships | Included in 9.5 Findings
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Fetus​Findings[*] |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.9 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (76514-9, LOINC, "Fetal Study observation") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > | subject | 1..1 | SHALL |  |  |  |
| >> | related​Subject | 1..1 | SHALL |  |  |  |
| >>> | code | 1..1 | SHALL | CE | SHALL | (121026, DCM, "Fetus") |
| >>> | subject | 1..1 | SHALL |  |  |  |
Fetus​ID | >>>> | name | 1..1 | SHALL | PN |  |  |
| > | component | 0..* | MAY |  |  |  |
Subsection[*] | >> | section | 1..1 | SHALL |  |  |  | 9.8.9 Labeled Subsection 1.2.840.10008.9.10
| > |  | 0.1 | MAY |  |  |  | 9.1.2 General Section Entries 1.2.840.10008.9.23

For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget/PatientRole/Patient in the CDA header. Information on the fetus is mapped to subject/relatedSubject/SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.

#### 9.8.8.1 name - FetusID

The subject/relatedSubject/subject/name element is used to store the fetus ID, typically a pseudonym such as "fetus A". This shall be present even if only one fetus is identified in the document.

Example 9.8.8-1. Fetus Findings section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.2.27" />
        <id root="1.2.840.10213.2.62.70447834679.11429737"/>
        <code code="76514-9" codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" displayName="Fetal Study observation" />
        <title>Fetus #1</title>
        <text>Estimated gestational age of 27 weeks... </text>
        <relatedSubject>
            <code code="121026" codeSystem="1.2.840.10008.2.16.4" displayName="Fetus"/>
            <subject>
                <name>Fetus 1</name>
            </subject>
        </relatedSubject>
    </section>

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