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

10.8 SOP Instance Observation
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## 10.8 SOP Instance Observation

Template ID | 1.2.840.10008.9.18
Name | SOP Instance Observation
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | A SOP Instance Observation contains the DICOM Service Object Pair (SOP) Instance information for referenced DICOM composite objects. The SOP Instance act class is used to reference both image and non-image DICOM instances. The text attribute contains the DICOM WADO reference.
Classification | CDA Entry Level
Relationships |
Context | parent node
Open/Closed | open
Revision History | DICOM-20150324: Initial publication, derived from template originally published in DIR r1-2009, revised in Consolidated CDA r1-2011 as 2.16.840.1.113883.10.20.6.2.8 This derivation includes Purpose of Reference value set specified with DICOM CID 7003; directly incorporates descendant templates Purpose of Reference Observation, Referenced Frames, and Boundary Observation

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
SOPInstance[*] |  | observation | 1..1 | SHALL |  |  |  |
| @ | @classCode | 1..1 | SHALL | CS | SHALL | DGIMG |
| @ | @moodCode | 1..1 | SHALL | CS | SHALL | EVN |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.18 |
SOPInstance​UID | > | id | 1..* | SHALL | II |  | SOP Instance UID (0008,0018) |
| > | code | 1..1 | SHALL | CD |  |  |
SOPClass​UID | >@ | @code | 1..1 | SHALL | ST |  | SOP Class UID (0008,0016) |
| >@ | @codeSystem | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.2.6.1 |
| > | text | 0..1 | SHOULD | ED |  |  |
| >@ | @mediaType | 1..1 | SHALL | ST | SHALL | application/dicom |
WADOReference | >> | reference | 1..1 | SHALL | URL |  |  |
| > | effective​Time | 0..1 | SHOULD | TS |  | Instance Creation Date (0008,0012) + Instance Creation Time (0008,0013) + Timezone Offset From UTC (0008,0201) |
| > | entry​Relationship | 0..* | COND |  |  |  |
| >@ | @typeCode | 1..1 | SHALL | CS | SHALL | SUBJ |
SOPInstance[*] | >> | observation | 1..1 | SHALL |  |  |  | 10.8 SOP Instance Observation 1.2.840.10008.9.18
| > | entry​Relationship | 0..1 | COND |  |  |  |
| >@ | @typeCode | 1..1 | SHALL | CS | SHALL | RSON |
| >> | observation | 1..1 | SHALL |  |  |  |
| >>@ | @classCode | 1..1 | SHALL | CS | SHALL | OBS |
| >>@ | @moodCode | 1..1 | SHALL | CS | SHALL | EVN |
| >>> | code | 1..1 | SHALL | CD | SHALL | (ASSERTION, ActCode [2.16.840.1.113883.5.4], "Assertion") |
Purpose​Of​Reference | >>> | value | 1..1 | SHALL | CD | SHALL CWE DYNAMIC | ValueSet CID 7003 “Diagnostic Imaging Report Purposes of Reference” |
| > | entry​Relationship | 0..1 | COND |  |  |  |
| >@ | @typeCode | 1..1 | SHALL | CS | SHALL | COMP |
| >> | observation | 1..1 | SHALL |  |  |  |
| >>@ | @classCode | 1..1 | SHALL | CS | SHALL | ROIBND |
| >>@ | @moodCode | 1..1 | SHALL | CS | SHALL | EVN |
| >> | code | 1..1 | SHALL | CD | SHALL | (121190, DCM, "Referenced Frames") |
| >> | entry​Relationship | 1..1 | SHALL |  |  |  |
| >>@ | @typeCode | 1..1 | SHALL | CS | SHALL | COMP |
| >>> | observation | 1..1 | SHALL |  |  |  |
| >>>@ | @classCode | 1..1 | SHALL | CS | SHALL | OBS |
| >>>@ | @moodCode | 1..1 | SHALL | CS | SHALL | EVN |
| >>> | code | 1..1 | SHALL | CD | SHALL | (113036, DCM, "Frames for Display") |
Referenced​Frames | >>> | value | 1..1 | SHALL | LIST <INT> |  |  |

### 10.8.1 entryRelationship

COND: entryRelationship SHALL NOT be present in a 10.8 SOP Instance Observation included within a 9.8.7 DICOM Object Catalog section, and MAY be present otherwise.

#### 10.8.1.1 entryRelationship/@typeCode=SUBJ (SOP Instance)

This template recursively invokes itself to allow a Presentation State SOP Instance reference to identify the target Image SOP Instances, or for a derived Image to reference its source Image, or similar linkages between instances.

### Note

This is generally not required, as the DICOM SOP Instance itself identifies relationships to the relevant other SOP Instances.

#### 10.8.1.2 entryRelationship/@typeCode=RSON (Purpose of Reference)

A Purpose of Reference Observation describes the purpose of the DICOM composite object reference. Appropriate codes, such as externally defined DICOM codes, may be used to specify the semantics of the purpose of reference. When this observation is absent, it implies that the reason for the reference is unknown.

### Note

In Consolidated CDA r1.1, this was defined using a separate "Purpose of Reference Observation" template, which is included directly in this template specification.

#### 10.8.1.3 entryRelationship/@typeCode=COMP (Referenced Frames)

A Referenced Frames Observation contains a list of integer values for the referenced frames of a DICOM multi-frame image SOP instance. It identifies the frame numbers within the referenced SOP instance to which the reference applies. The observation identifies frames using the same convention as DICOM, with the first frame in the referenced object being Frame 1. A Referenced Frames Observation must be used if a referenced DICOM SOP instance is a multi-frame image and the reference does not apply to all frames.

### Note

In Consolidated CDA r1.1, this was defined using separate "Referenced Frames Observation" and "Boundary Observation" templates, which are included directly in this template specification.

Example 10.8-1. SOP instance observation example with purpose of reference

    <observation classCode="DGIMG" moodCode="EVN">
        <templateId root="1.2.840.10008.9.18"/>
        <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/>
        <code code="1.2.840.10008.5.1.4.1.1.1"
            codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
            displayName="Computed Radiography Image">
        </code>
        <text mediaType="application/dicom">
            <reference value="http://www.example.org/wado?requestType=WADO
                &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                &amp;contentType=application/dicom"/>
            <!--reference to image 1 (PA) -->
        </text>
        <effectiveTime value="20060823223232"/>
        <entryRelationship typeCode="RSON">
            <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.6.2.9"/>
                <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
                <value xsi:type="CD" code="121112"
                    codeSystem="1.2.840.10008.2.16.4"
                    codeSystemName="DCM"
                    displayName="Source of Measurement"/>
            </observation>
        </entryRelationship>
    </observation>

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