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

9.8.10 Communication of Actionable Findings
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### 9.8.10 Communication of Actionable Findings

Template ID | 1.2.840.10008.9.11
Name | Communication of Actionable Findings
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | A section that documents the notification of an actionable finding to a provider or other person responsible for patient care. The documentation in narrative text, and optionally in a coded entry, includes by whom, to whom, and at what date/time. Specific findings, including actionable (aka. critical) findings documented in text or as coded entries, are typically found in the 9.5 Findings. The actionable findings may be duplicated in the 9.6 Impression in either text or as coded entries. The actionable findings may be new (critical) or a change to a previous report/diagnosis (discrepant).
Classification | CDA Section and Entry Level
Relationships | Included in 9.6 Impression and 9.7 Addendum
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Actionable​Findings |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.11 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (73568-8, LOINC, "Communication of Critical Results") |
Title | > | title | 1..1 | SHALL | ST |  |  |
| > | text | 1..1 | SHALL | ED |  |  |
Content[*] | >> | content | 0..* | SHALL | ST |  | [See 9.8.10.1 section/text/content - narrative] |
* | >>@ | @ID | 1..1 | SHALL | XML ID |  |  |
Finding​Ref | >>> | link​Html | 0..* | MAY | ST |  |  |
Finding​URI | >>>@ | @href | 1..1 | SHALL | URL (XML IDREF) |  | #findingRef |
| > | entry | 0..* | SHOULD |  |  |  |
Communication[*] | >> | act | 1..1 | SHALL |  | SHALL |  |
| >>@ | @classCode | 1..1 | SHALL | CS | SHALL | ACT |
| >>@ | @moodCode | 1..1 | SHALL | CS | SHALL | EVN |
* | >>@ | @ID | 1..1 | SHALL | XML ID |  |  |
| >>> | code | 1..1 | SHALL | CD | SHALL | (121291, DCM, "Results communicated") |
Comm​Time | >>> | effective​Time | 1..1 | SHALL | TS |  |  |
| >>> | text | 1..1 | SHALL | ED |  |  |
Ref | >>>> | reference | 1..1 | SHALL | URL (XML IDREF) |  | # content​Ref |
| >>> | performer | 1..1 | SHALL |  |  |  |
| >>>> | assigned​Entity | 1..1 | SHALL |  |  |  |
| >>>>> | assignedPerson | 1..1 | SHALL |  |  |  |
Reporting​Physician​Name | >>>>>> | name | 1..1 | SHALL | PN |  |  |
| >>> | participant | 1..1 | SHALL |  |  |  |
| >>>@ | @typeCode | 1..1 | SHALL | CS | SHALL | NOT |
| >>>> | participant​Role | 1..1 | SHALL |  |  |  |
Notification​Contact​Telecom | >>>>> | telecom | 1..1 | SHALL | TEL |  |  |
| >>>>> | playing​Entity | 1..1 | SHALL |  |  |  |
Notification​Contact​Name | >>>>>> | name | 1..1 | SHALL | PN |  |  |

#### 9.8.10.1 section/text/content - narrative

Each documented act of communication of actionable findings SHALL be included as narrative in a section/text/content element, labeled with an XML ID (see Section 9.1.1.1).

### Note

The following text content for such a block is specified in the RSNA Radiology Reporting Templates, Template 297: Communication of Actionable Finding (http://radreport.org/txt-mrrt/0000297):

method [discussed directly | discussed by telephone | described in message]

by [person]

to [person]

on [<date>] at [<time>]

The documentation may also provide a linkHtml reference to the actionable finding narrative elsewhere in the report, e.g., in the 9.5 Findings or 9.8.4 Complicationssection (see Section 9.1.1.2).

Example 9.8.10-1. Communication of Actionable Results section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="1.2.840.10008.9.11"/>
        <id root="1.2.840.10213.2.62.7044794679.114296787"/>
        <code code="73568-8"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC"
            displayName="Communication of Critical Results"/>
        <title>Communication of Actionable Results</title>
        <text>
            <content ID=CR1>Dr. Smith was phoned at 262-966-0120 at 3:14pm on
            Wednesday, June 4, 2014, and the 4mm lung nodule was discussed directly
            with Dr. Smith to explain the follow-up recommendation of ...</content>
        </text>
        <entry>
            <act classCode="ACT" moodCode="EVN">
                <code code="121291"
                    codeSystem="1.2.840.10008.2.16.4"
                    codeSystemName="DCM"
                    displayName="Results Communicated"/>
                <text>
                    <reference value="#CR1"/>
                </text>
                <effectiveTime value="20140604221400-0700"/>
                <performer>
                    <assignedEntity>
                        <id root="1.2.840.10213.2.62.7044794679.114298686"/>
                        <assignedPerson>
                            <name>Jane Doctor</name>
                        </assignedPerson>
                    </assignedEntity>
                </performer>
                <participant typeCode="NOT">
                    <participantRole>
                        <telecom value="tel:262-966-0120"/>
                        <playingEntity>
                            <name>Dr. Smith</name>
                        </playingEntity>
                    </participantRole>
                </participant>
            </act>
        </entry>
    </section>

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