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

C.4 Body Transformation
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## C.4 Body Transformation

For transformation of the body, this Section maps the SR content items to their target CDA elements. This allows the transforming application to traverse the SR content tree and construct equivalent CDA content.

### C.4.1 Section Mapping

SR TID 2000, TID 2005 and TID 2006 specify that imaging report elements are contained in sections, represented as CONTAINERs with concept name codes from CID 7001.

Each CONTAINER immediately subsidiary to the root CONTAINER shall be mapped to the section or subsection as specified in Table C.4-1. Note that some SR document sections are mapped to subsections under CDA Template 1.2.840.10008.9.1.

Table C.4-1. SR Section mapping to CDA

Coding Scheme Designator | Code Value | Code Meaning | Map to Template Section/Subsection
--- | --- | --- | ---
LN | 11329-0 | History | 9.2 Clinical Information / 9.8.3 Medical (General) History
LN | 55115-0 | Request | 9.2 Clinical Information / 9.8.1 Request
LN | 55111-9 | Current Procedure Descriptions | 9.3 Imaging Procedure Description
LN | 55114-3 | Prior Procedure Descriptions | 9.4 Comparison Study
LN | 18834-2 | Previous Findings | 9.4 Comparison Study
LN | 18782-3 | Findings (Study Observation) | 9.5 Findings or 9.5 Findings / 9.8.8 Fetus Findings (see C.4.1.3)
LN | 59776-5 | Findings | 9.5 Findings or 9.5 Findings / 9.8.8 Fetus Findings (see C.4.1.3)
LN | 19005-8 | Impressions | 9.6 Impression
LN | 18783-1 | Recommendations | 9.6 Impression / 9.8.11 Recommendation
LN | 55110-1 | Conclusions | 9.6 Impression
LN | 55107-7 | Addendum | 9.7 Addendum
LN | 18785-6 | Indications for Procedure | 9.2 Clinical Information / 9.8.2 Procedure Indications
LN | 55108-5 | Patient Presentation | 9.2 Clinical Information
LN | 55109-3 | Complications | 9.3 Imaging Procedure Description / 9.8.4 Complications
LN | 55112-7 | Summary | 9.6 Impression
LN | 55113-5 | Key Images | 9.6 Impression / 9.8.6 Key Images
LN | 73569-6 | Radiation Exposure and Protection Information | 9.3 Imaging Procedure Description / 9.8.5 Radiation Exposure and Protection Information
LN | 55752-0 | Clinical Information | 9.2 Clinical Information
LN | 29549-3 | Medications Administered | 9.3 Imaging Procedure Description / 10.2 Procedural Medication
LN | 73568-8 | Communication of Critical Results | 9.6 Impression / 9.8.10 Communication of Actionable Findings

CDA Template 1.2.840.10008.9.1 requires a minimum of an Imaging Procedure Description section and an Impression section.

The section/code element shall be populated in accordance with the relevant CDA template; note that the code might not be the same as the Concept Name code of the SR section CONTAINER. The title element of each CDA section shall be populated as shown in Table C.4-2.

Table C.4-2. CDA Section mapping from SR

CDA Business Name | DICOM SR
--- | ---
<section>: Title | Concept Name Code Sequence (0040,A043) > Code Meaning (0008,0104) [of the section CONTAINER content item]
<section>: Text | [See C.4.2]
<section>: CodedObservation[*] | [See C.4.3.1 and C.4.3.2]
<section>: QuantityMeasurement[*] | [See C.4.3.4]
<section>: SOPInstance[*] | [See C.4.3.3]

SR allows sections to be qualified by observation context, using TID 1001 and its subsidiary templates. This capability is constrained in this mapping.

#### C.4.1.1 Section Observer Context

TID 1002 Observer Context allows identification of a human or device author.

Table C.4-3. CDA Section author mapping from SR

CDA Business Name | DICOM SR
--- | ---
<section>: AuthorID | If (121005, DCM, "Observer Type") = (121007, DCM, "Device"), then (121012, DCM, "Device Observer UID") ID for human observer not represented in SR; use nullFlavor="UNK"
<section>: AuthorName | (121008, DCM, "Person Observer Name")
<section>: AuthorOrganization | (121009, DCM, "Person Observer's Organization Name")
<section>: AuthorDeviceModel | (121015, DCM, "Device Observer Model Name")
<section>: AuthorSoftware | (121013, DCM, "Device Observer Name")

#### C.4.1.2 Comparison Study Procedure Context

TID 1005 Procedure Context allows identification of a different procedure than the procedure identified in the SR Study IE as the context for the section observations. In the transformations of this Annex, only an identified comparison procedure is supported as Procedure Context, the SR section being transformed must be either Prior Procedure Descriptions or Previous Findings, and the CDA section shall be in accordance with the Comparison Study section Template 1.2.840.10008.9.4.

SR Instances using TID 2006 have additional attributes of a comparison procedure specified using TID 2007, which is used in the Prior Procedure Descriptions section. The attributes of both TID 1005 and TID 2007 are source data in the Table C.4-4 mapping.

Table C.4-4. Comparison Study mapping from SR

CDA Business Name | DICOM SR
--- | ---
ComparisonStudy: ProcedureTechnique: ProcedureCode | (121023, DCM, "Procedure Code")
ComparisonStudy: ProcedureTechnique: EffectiveTime | (111060, DCM, "Study Date") + (111061, DCM, "Study Time")
ComparisonStudy: ProcedureTechnique: Modality | (122142, DCM, "Acquisition Device Type")
ComparisonStudy: ProcedureTechnique: MethodCode |
ComparisonStudy: ProcedureTechnique: TargetSite | (123014, DCM,"Target Region")
ComparisonStudy: ProcedureTechnique: Laterality: |
ComparisonStudy: ProcedureTechnique: Ref: |
ComparisonStudy: ProcedureTechnique: ProviderOrganization |
ComparisonStudy: Study[*]: StudyUID | (121018, DCM, "Procedure Study Instance UID")
ComparisonStudy: Study[*]: Description | (121065, DCM, "Procedure Description") , if present, or (121023, DCM, "Procedure Code") > Code Meaning (0008,0104)
ComparisonStudy: Study[*]: Time | (111060, DCM, "Study Date") + (111061, DCM, "Study Time")

#### C.4.1.3 Fetus Subject Context

TID 1006 Subject Context allows identification of a different subject than the patient identified in the SR Patient IE. In the transformations of this Annex, only an identified fetus subject is supported as Subject Context for a Findings section. An SR section with a fetus subject context shall be mapped to a CDA section shall be in accordance with the Fetus Findings subsection Template 1.2.840.10008.9.9. This section is subsidiary to the top level Findings section; multiple SR fetus findings sections may be mapped to separate CDA Fetus Findings subsections.

Table C.4-5. CDA Fetus subject mapping from SR

CDA Business Name | DICOM SR
--- | ---
Findings: FetusFindings[*]: FetusID | (121030, DCM, "Subject ID") or (11951-1, LN, "Fetus ID")

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