DICOM PS3.20 2017a - Imaging Reports using HL7 Clinical Document Architecture

9 Section-level Templates
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# 9 Section-level Templates

## 9.1 General Requirements For Sections

### 9.1.1 Section Text

Template ID | 1.2.840.10008.9.19
Name | Section Text
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | This template specifies the common set of narrative block markup that may be included in a CDA imaging report section.
Classification | CDA Element Set
Relationships | Included in all sections
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Text |  | text | 1..1 | COND | ED |  |  |
Content[*] | > | content | 0..* | MAY | ST |  |  |
* | >@ | @ID | 1..1 | SHALL | XML ID |  | [See 5.3.4 XML ID] |
Style | >@ | @styleCode | 0..1 | MAY | XML NMTOKENS |  |  |
Int​Ref[*] | > | link​Html | 0..* | MAY | ST |  |  |
| >@ | @href | 1..1 | SHALL | ST (URL - XML IDREF) |  |  |
Graphic​Ref[*] | > | render​Multi​Media | 0..* | MAY |  |  |  |
| >@ | @referencedObject | 1..1 | SHALL | XML IDREF |  |  |
Caption | >> | caption | 0..1 | MAY | ST |  |  |
Ext​Ref[*] | > | link​Html | 0..* | MAY | ST |  |  |
URL | >@ | @href | 1..1 | SHALL | ST (URL) |  |  |
Paragraph(*) | > | paragraph | 0..* | MAY | ST |  |  |
Caption | >> | caption | 0..1 | MAY | ST |  |  |
List(*) | > | list | 0..* | MAY | ST |  |  |
* | >@ | @ID | 1..1 | SHALL | XML ID |  | [See 5.3.4 XML ID] |
Ordered | >@ | @listType | 0..1 | MAY | XML NMTOKENS | SHALL | ordered |
Caption | >> | caption | 0..1 | MAY | ST |  |  |
Item(*) | >> | item | 1..* | SHALL | ST |  |  |
* | >>@ | @ID | 1..1 | SHALL | XML ID |  | [See 5.3.4 XML ID] |
Table(*) | > | table | 1..1 | SHALL |  |  |  |
* | >@ | @ID | 1..1 | SHALL | XML ID |  | [See 5.3.4 XML ID] |
Caption | >> | caption | 0..1 | MAY | ST |  |  |
| >> | Tr | 1..1 | SHALL |  |  |  |
| >>@ | @styleCode | 1..1 | SHALL | CS | SHALL | Bold |
Column​Head(*) | >>> | Th | 1..* | SHALL | ST |  |  |
Row[*] | >> | Tr | 1..* | SHALL |  |  |  |
* | >>@ | @ID | 1..1 | SHALL | XML ID |  |  |
Cell(*) | >>> | Td | 1..1 | SHALL | ST |  |  |

The text element within the section stores the narrative to be rendered, as described in the CDA R2 specification, and is referred to as the CDA narrative block.

COND: The text element SHALL be present if the section content is not completely represented by subsections.

As noted in the CDA R2 specification, the document originator is responsible for ensuring that the narrative block contains the complete, human readable, attested content of the section. Structured entries support computer processing and computation, and are not a replacement for the attestable, human-readable content of the CDA narrative block.

Additional specification information for the CDA narrative block can be found in the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.

The narrative block allows a variety of markup. The markup that implements various types of internal and external linkage is shown in the table, and is included in the conformance specifications for each section narrative block that invokes this template. The markup elements may occur in any order and at any point within the narrative block text as allowed by the CDA R2 specification.

#### 9.1.1.1 <content> Markup and Links From Entries

The CDA narrative block may contain the <content> markup element to wrap a block of text so that it can be explicitly identified using its XML ID attribute, and referenced from elsewhere in the document. Specifically, structured entries may link to their equivalent narrative rendering in a content block using the XML ID (see CDA R2 Specification, section 4.3.5.1).

Additionally, a content block may include a styleCode attribute to suggest rendering (see CDA R2 Specification, section 4.3.5.11). For example, Bold could also be used to highlight actionable findings in the text of the 9.5 Findings and/or 9.6 Impression sections.

#### 9.1.1.2 <linkHtml> Markup and Internal References

The CDA narrative block MAY contain the <linkHtml> markup to provide a link between narrative text in one section and a content block in another section (see CDA R2 specification section 4.3.5.2). The XML ID of the target content block is used in the linkHtml href attribute, with a prefixed '#' to indicate the reference is in the current document.

For example, a linkHtml reference could be used to link an actionable finding in the 9.6 Impression section to the specific, detailed measurement evidencing a problem that was identified in the text of the 9.5 Findings section.

#### 9.1.1.3 <renderMultiMedia> Markup and Graphical Content

The CDA narrative block MAY contain the <renderMultiMedia> markup element to include graphical content, e.g., a coronary tree diagram or myocardial wall motion "bulls-eye chart". The renderMultiMedia element SHALL link to an observationMedia structured entry using the XML ID of that entry (see CDA R2 Specification, section 4.3.5.6).

#### 9.1.1.4 <linkHtml> Markup and External References

The CDA narrative block MAY contain the <linkHtml> markup to provide a link between narrative text and an external (non-attested) resource (see CDA R2 specification section 4.3.5.2).

### Note

For radiology reports, this capability may be used to tag concepts in the narrative block to concepts defined in the RadLex terminology (http://www.radlex.org), developed by the Radiological Society of North America. The RadLex coded vocabulary is a useful tool for indexing report content for data mining purposes. It is not intended to be a complete grammar for expression of clinical statements, but rather a lexicon for tagging concepts of interest.

Within the report section narrative blocks, RadLex codes may be included using the <linkHtml> element and a URI pointing to the RadLex resource. <linkHtml> elements may be embedded in the text at the location of the concept (within the scope of a content tag), or may be provided in a list at the end of the narrative block.

Example 9.1.1.4-1. Example - linkHtml references at point of use for RadLex

    <section>
        ...
        <text>
            ...
            <content ID="find1">There is focal opacity
                <linkHtml href="http://www.radlex.org/RID/RID28530"/>
                at the right lung
                <linkHtml href="http://www.radlex.org/RID/RID1302"/>
                base most likely representing right lower lobe atelectasis
                <linkHtml href="http://www.radlex.org/RID/RID28493"/>.
            </content>
            <content ID="find2">The mediastinum ...</content>
        </text>
        ...
    </section>

Example 9.1.1.4-2. Example- linkHtml references at end of narrative block for RadLex

    <section>
        <title>Findings</title>
        <text>
            <content ID="find1">Pleura normal... </content>
            <linkHtml href="http://www.radlex.org/RID/RID1362"/>
        </text>
    </section>

#### 9.1.1.5 <linkHtml> Markup and Image References

The text elements (and their children) MAY contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL. The text content of linkHtml MAY be either the visible text of the hyperlink, or a descriptor or identifier of the image.

The linkHtml may be associated with a <renderMultiMedia> markup element to specify a (limited resolution) copy of the image to be rendered in the narrative (e.g., a thumbnail); the renderMultiMedia element SHALL link to an observationMedia structured entry using the XML ID of that entry. As CDA does not allow use of an image as the linkHtml displayable hyper-linked content, the linkHtml should immediately follow the renderMultiMedia for the thumbnail.

Example 9.1.1.5-1. Example linkHtml reference for WADO image access

    <text>
        ...
        <paragraph>
            <caption>Source of Measurement</caption>
            <renderMultiMedia referencedObject="#thumb1"/>
            <linkHtml href="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">Chest_PA</linkHtml>
        </paragraph>
        ...
    </text>

#### 9.1.1.6 list

This template specifies a structure and Business Names for list markup in the narrative text, as described in the CDA Specification section 4.3.5.8. Inclusion of the listType="ordered" attribute specifies a numbered list of items.

Each list is identified by an XML ID attribute, and each list item also is identified by an XML ID attribute.

The list items contain human readable displayable text using any of the narrative text structures permitted in section/text, including internal, external, or image references, or graphics. Processable structured data may be encoded in 10.1 Coded Observation or 10.5 Quantity Measurement entries in the section. Such observation entries SHOULD be linked to the corresponding item through the ID attribute of the item (see Section 10.1.2 and Section 10.5.1).

#### 9.1.1.7 table

This template specifies a structure and Business Names for table markup in the narrative text, as described in the CDA Specification section 4.3.5.9, typically used for a table of measurements. The table may be of arbitrary size.

### Note

See Travis, A., et al., "Preferences for Structured Reporting of Measurement Data", JAcadRadiology 21:6 DOI:10.1016/j.acra.2014.02.008

Each table is identified by an XML ID attribute, and each table row also is identified by an XML ID attribute.

The table cells contain human readable displayable text using any of the narrative text structures permitted in section/text, including internal, external, or image references, or graphics. Processable structured data may be encoded in 10.1 Coded Observation or 10.5 Quantity Measurement entries in the section. Such observation entries SHOULD be linked to the corresponding row through the ID attribute of the row (see Section 10.1.2 and Section 10.5.1).

Example 9.1.1.7-1. Measurements Table Example 1

As displayed

Table . Cardiac Measurements

Measurement name | Value | Flag
--- | --- | ---
Left ventricular ejection fraction | 40 % | LOW
Left ventricle end diastolic volume | 120 ml |
Left ventricle end systolic volume | 72 ml |

As encoded in CDA instance

    <text>
    	<table ID="T-C">
    		<caption>Cardiac Measurements</caption>
    		<tr styleCode="Bold">
    			<th>Measurement name</th>
    			<th>Value</th>
    			<th>Flag</th>
    		</tr>
    		<tr ID="Q1">
    			<td>Left ventricular ejection fraction</td>
    			<td>40 %</td>
    			<td styleCode="Bold">LOW</td>
    		</tr>
    		<tr ID="Q2">
    			<td>Left ventricle end diastolic volume</td>
    			<td>120 ml</td>
    		</tr>
    		<tr ID="Q3">
    			<td>Left ventricle end systolic volume</td>
    			<td>72 ml</td>
    		</tr>
    	</table>
    </text>
    <entry>
    	<observation classCode="OBS" moodCode="EVN">
    		<templateId root="2.16.840.1.113883.10.20.6.2.14"/>
    		<id root="1.2.840.10213.2.62.7044234.11652014"/>
    		<code code="10230-1" codeSystem="2.16.840.1.113883.6.1"
    		    codeSystemName="LOINC" displayName="LVEF" />
    		<text><reference value="#Q1"/></text>
    		<statusCode code="completed"/>
    		<effectiveTime value="20140913223912"/>
    		<value xsi:type="PQ" unit="%" value="40" />
    		<interpretationCode code="L" codeSystem="2.16.840.1.113883.6.83"
    		    codeSystemName="ObservationInterpretation" displayName="Low" />
    	</observation>
    </entry>
    <entry>
    	<observation classCode="OBS" moodCode="EVN">
    		<templateId root="2.16.840.1.113883.10.20.6.2.14"/>
    		<id root="1.2.840.10213.2.62.7044234.11652014"/>
    		<code code="8821-1" codeSystem="2.16.840.1.113883.6.1"
    		    codeSystemName="LOINC" displayName="LVEDV" />
    		<text><reference value="#Q2"/></text>
    		<statusCode code="completed"/>
    		<effectiveTime value="20140913223912"/>
    		<value xsi:type="PQ" unit="ml" value="120" />
    	</observation>
    </entry>
    <entry>
    	<observation classCode="OBS" moodCode="EVN">
    		<templateId root="2.16.840.1.113883.10.20.6.2.14"/>
    		<id root="1.2.840.10213.2.62.7044234.11652014"/>
    		<code code="8823-7" codeSystem="2.16.840.1.113883.6.1"
    		    codeSystemName="LOINC" displayName="LVESV" />
    		<text><reference value="#Q3"/></text>
    		<statusCode code="completed"/>
    		<effectiveTime value="20140913223912"/>
    		<value xsi:type="PQ" unit="ml" value="72" />
    	</observation>
    </entry>

Example 9.1.1.7-2. Measurements Table Example 2

As displayed

Table . Current Lesion Sizes with Comparison to Exam on 2014/11/16

Ref | Measurement name | Current Value | Prior Value | Image Reference
--- | --- | --- | --- | ---
L1 | Left periaortic lymph node size (mm) | 12 x 8 | 15 x 10 | Ser:3, Img:67
L2 | Segment 2 left lobe lesion size (mm) | 6 x 8 | 10 x 9 | Ser:3, Img:79
L3 | Left common iliac lymph node size (mm) | 12 x 3 | 16 x 5 | Ser:3, Img:139

As encoded in CDA instance

    <text>
    	<table ID="Table2">
    		<caption>Current Lesion Sizes with Comparison to Exam on 2014/11/16</caption>
    		<tr styleCode="Bold">
    			<td>Ref</td>
    			<td>Measurement name</td>
    			<td>Current Value</td>
    			<td>Prior Value</td>
    			<td>Image Reference</td>
    		</tr>
    		<tr ID="lesRow1">
    			<td>L1</td>
    			<td>Left periaortic lymph node size (mm) </td>
    			<td>12 x 8</td>
    			<td>15 x 10</td>
    			<td><linkHtml href="http://wado.pacs.guh.org/..." >Ser:3, Img:67</linkHtml></td>
    		</tr>
    		...
    	</table>
    </text>

### 9.1.2 General Section Entries

Template ID | 1.2.840.10008.9.23
Name | General Section Entries
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | This template specifies the common set of structured entries that may be included in a CDA imaging report section, and an author participation for the section.
Classification | CDA Element Set
Relationships | Included in 9.5 Findings section and its sub-sections, 9.2 Clinical Information and other sections
Context | sibling 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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Content​Template |  | template​Id | 0..1 | MAY | II |  |  |
|  | author | 0..* | MAY |  |  |  |
Authoring​Time | > | time | 1..1 | SHALL | TS |  |  |
| > | assigned​Author | 1..1 | SHALL |  |  |  |
Author​ID | >> | id | 1.* | SHALL | II |  |  |
| >> | assigned​Person | 1..1 | COND |  |  |  |
Author​Name | >>> | name | 1..1 | SHALL | PN |  |  |
| >> | assigned​Authoring​Device | 1..1 | COND |  |  |  |
Author​Device​Model | >>> | manufacturer​Model​Name | 0..1 | SHOULD | ST |  |  |
Author​Software | >>> | software​Name | 0..1 | SHOULD | ST |  |  |
| >> | represented​Organization | 0..1 | MAY |  |  |  |
Author​Organization | >>> | name | 0..1 | SHOULD | ON |  |  |
|  | entry | 0..* | MAY |  |  |  |
Coded​Observation[*] | > | observation | 1..1 | SHALL |  |  |  | 10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13
|  | entry | 0..* | MAY |  |  |  |
Quantity​Measurement[*] | > | observation | 1..1 | SHALL |  |  |  | 10.5 Quantity Measurement 2.16.840.1.113883.​10.20.6.2.14
|  | entry | 0..* | MAY |  |  |  |
Graphic[*] | > | observation​Media | 1..1 | SHALL |  |  |  | 10.3 observationMedia 1.3.6.1.4.1.19376.​1.4.1.4.7
|  | entry | 0..* | MAY |  |  |  |
SOPInstance[*] | > | observation | 1..1 | SHALL |  |  |  | 10.8 SOP Instance Observation 1.2.840.10008.9.18
|  | entry | 0..* | MAY |  |  |  |
| > | region​Of​Interest | 0..0 | SHALL NOT |  |  |  |

Note that there is no business name associated with this template. Rather, this template is an editorial convenience for template specification, and the Business Names for the elements of this template are logically part of the Business Name scope of the invoking template.

Also, the ID of this template is not represented in a templateID element. Rather, the templateID of the invoking template implicitly includes the elements specified by this template.

#### 9.1.2.1 templateId

This templateId may be used to identify the template(s) used to generate/constrain the content of the section. This is in addition to the templateId of the section level template, and typically represents clinical sub-specialty requirements. See Section 5.1.1 on the structure and use of the templateId.

#### 9.1.2.2 author

The author participation allows the recording of an author for a section, equivalent to the TID 1002 “Observer Context”. Either a person or a device may be identified as the author for a section or subsection.

COND: Either the assignedPerson or assignedAuthoringDevice element SHALL be present.

Example 9.1.2.2-1. Author example

    <author>
        <assignedAuthor>
            <id extension="121008" root="2.16.840.1.113883.19.5"/>
            <assignedPerson>
                <name>
                    <given>John</given>
                    <family>Blitz</family>
                    <suffix>MD</suffix>
                </name>
            </assignedPerson>
        </assignedAuthor>
    </author>

#### 9.1.2.3 section/entry

A section may contain CDA entries that represent clinical statements in coded form (using the 10.1 Coded Observation template), numeric measurements (using the 10.5 Quantity Measurement template), images to be displayed in the narrative block (using the 10.3 observationMedia template, and invoked from a renderMultiMedia element), or references to external images or annotated images (using the 10.8 SOP Instance Observation template).

These entries may appear in any order.

#### 9.1.2.4 regionOfInterest

Section templates defined in this Implementation guide SHALL NOT use the CDA Region of Interest Overlay entry (classCode="ROIOVL"). If it is desired to show images with graphical annotations, the annotations SHOULD be encoded in DICOM Presentation State objects that reference the image. Report applications that display referenced images and annotation may retrieve a rendered image using a WADO reference in accordance with PS3.18, including the image and Presentation State, or other DICOM retrieval and rendering methods. This approach avoids the risks of errors in registering a CDA region of interest annotation with DICOM images, and places all image rendering within the scope of the DICOM Standard, including the full range of 2D and 3D presentations defined in DICOM.

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DICOM PS3.20 2017a - Imaging Reports using HL7 Clinical Document Architecture