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

9.3 Imaging Procedure Description
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## 9.3 Imaging Procedure Description

Template ID | 1.2.840.10008.9.3
Name | Imaging Procedure Description
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | The Imaging Procedure Description section records the technical details of the procedure and may include information about protocol, imaging device, contrast, radiation dose, medications administered (sedation, stress agents), etc.
Classification | CDA Section Level
Relationships | Included in 7.1 Imaging Report
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Procedure​Description |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.3 |
| > | id | 1..1 | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (55111-9, LOINC, "Current Imaging Procedure Description") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > | entry | 1..1 | SHALL |  |  |  |
Procedure​Technique | >> | procedure | 1..1 | SHALL |  |  |  | 10.4 Procedure Technique 1.2.840.10008.9.14
| > | entry | 0..* | MAY |  |  |  |
Procedural​Medication[*] | >> | substance​Administration | 1..1 | SHALL |  |  |  | 10.2 Procedural Medication 1.2.840.10008.9.13
| > | component | 0..1 | MAY |  |  |  |
Complications | >> | section | 1..1 | SHALL |  |  |  | 9.8.4 Complications 2.16.840.1.113883.​10.20.22.2.37
| > | component | 0..1 | COND |  |  |  |
Radiation​Exposure | >> | section | 1..1 | SHALL |  |  |  | 9.8.5 Radiation Exposure and Protection Information 1.2.840.10008.9.8
| > | component | 1..1 | SHALL |  |  |  |
DICOMObject​Catalog | >> | section | 1..1 | SHALL |  |  |  | 9.8.7 DICOM Object Catalog 2.16.840.1.113883.​10.20.6.1.1
| > | entry | 0..1 | MAY |  |  |  |
Image​Quality | >> | observation | 1..1 | SHALL |  |  |  | 10.9 Image Quality 1.2.840.10008.9.15

Example 9.3-1. Current Imaging Procedure description section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="1.2.840.10008.9.3"/>
        <id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/>
        <code code="55111-9" codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" displayName="Current Imaging Procedure Description"/>
        <title>Imaging Procedure Description</title>
        <text>A CT study was acquired with 2.5 mm images of the abdomen and pelvis with 140 ml of... </text>
        <!-- See Procedure Technique template example - required here -->
        <!-- See DICOM Imaging Catalog template example - required here -->
        <!---see examples for other sections/entries -->
    </section>

### 9.3.1 component/section Radiation Exposure and Protection Information

COND: If the documented service utilizes ionizing radiation, a 9.8.5 Radiation Exposure and Protection Information section MAY be present.

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