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

9.2 Clinical Information
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## 9.2 Clinical Information

Template ID | 1.2.840.10008.9.2
Name | Clinical Information
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, 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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Clinical​Information |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.2 |
| > | id | 1..1 | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (55752-0, LOINC, "Clinical Information") |
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..1 | MAY |  |  |  |
Request | >> | section | 1..1 | SHALL |  |  |  | 9.8.1 Request 1.2.840.10008.9.7
| > | component | 0..1 | MAY |  |  |  |
Procedure​Indications | >> | section | 1..1 | SHALL |  |  |  | 9.8.2 Procedure Indications 1.2.840.10008.9.22
| > | component | 0..1 | MAY |  |  |  |
History | >> | section | 1..1 | SHALL |  |  |  | 9.8.3 Medical (General) History 2.16.840.1.113883.​10.20.22.2.39
| > |  | 0..1 | MAY |  |  |  | 9.1.2 General Section Entries 1.2.840.10008.9.23

Example 9.2-1. Clinical Information section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="1.2.840.10008.9.2"/>
        <id root="1.2.840.10213.2.62.994044785528.114289542805"/>
        <code code="55752-0" codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" displayName="Clinical Information"/>
        <title>Clinical Information</title>
        <text>The patient was referred for evaluation of suspected pulmonary embolism.</text>
        <!---see examples for other sections/entries -->
    </section>

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