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

9.5 Findings
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## 9.5 Findings

Template ID | 2.16.840.1.113883.​10.20.6.1.2
Name | Findings
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | Records clinically significant observations confirmed or discovered during the procedure.
Classification | CDA Section Level
Relationships | Included in 7.1 Imaging Report
Context | parent node
Open/Closed | Open
Revision History | From Consolidated CDA r1.1 DICOM-20150324: Added optional subsections and entries

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
Findings |  | section |  |  |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 2.16.840.1.113883.​10.20.6.1.2 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (59776-5, LOINC, "Procedure Findings") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > | component | 0..* | MAY |  |  |  |
Fetus​Findings[*] | >> | section | 1..1 | SHALL |  |  |  | 9.8.8 Fetus Findings 1.2.840.10008.9.9
| > | 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

### 9.5.1 text

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>

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