| DICOM PS3.16 2018a - Content Mapping Resource |
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This Annex specifies the content of Standard Templates that may be used by DICOM SR IODs.
This Template provides a general structure for a numeric measurement, together with evaluations of its normality and/or significance, and the inference source(s) for its value. This structure is instantiated by inclusion of this Template with specific contextual parameters from a parent Template.
Table TID 300. Parameters
Table TID 300. Measurement
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EV (126100, DCM, "Real World Value Map used for measurement") |
SOP Class UID shall be Real World Value Mapping Storage ("1.2.840.10008.5.1.4.1.1.67") |
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This Template provides the properties of a numeric measurement, including evaluations of its normality and/or significance, its relationship to a reference population, and an indication of its selection from a set of measurements.
This Template provides the statistical properties of a reference population for a numeric measurement, and/or the position of a measurement in such a reference population.
This Template provides the normal range of values for a numeric measurement.
This Template provides a general structure for inference from an image, either as a whole, or with specific spatial coordinates, as a single included Template in the invoking Template. If allowed by the IOD, the Image Content Item may be included by-reference.
This Template provides a general structure for referencing a waveform, either as a whole, or with specific temporal coordinates, as a single included Template in the invoking Template. If allowed by the IOD, the Waveform Content Item may be included by-reference.
This Template provides references to supporting evidence in the form of DICOM composite objects. This includes references to images, spatial coordinates on images, and other composite objects, such as Structured Reports.
This general Template provides a means to reference previous structured reporting composite object instances.
This TID is a subset of the Reference Location Macro. See Section 10.27 “Reference Location Macro” in PS3.3 .
Unless otherwise specified, content in an SR tree is "directly" observed. When material is quoted (from a source that is either a document or something spoken), then it is necessary to specify:
This Template establishes a mechanism for quoting by specifying:
the fact that one is quoting, by the presence of the contents of the Template in the tree
that the "observer context" above the invocation of this Template establishes who is doing the quoting
the source of the quote, by the values of the Content Items in this Template
who is being quoted, and who and what the quote is about, by the observation context that is established at the start of the quoted material
This Template may be invoked recursively, to nest quotes within quotes. In essence, the chain of who is quoting whom can be established by maintaining a "stack" of observer context.
If a dimension of observation context is the same in the quoted material as in the enclosing tree, then the observation context does not need to be respecified (e.g., the quote may be about the same subject or procedure). Typically, the observer context would change (unless one were quoting oneself).
In the case of quoting something that was spoken, the "observer" is the person speaking.
TID 1000 is attached using HAS OBS CONTEXT relationships to the top node of the material that is being quoted. The presence of the Quoted Source concept signals the fact that the material is quoted rather than directly observed.
Specifies attributes of observation context that may be defined, extended or replaced at any location in the SR tree.
This includes attributes that specify:
Establishing context includes two aspects of each dimension: identification and description (e.g., patient name and ID vs. patient's age, height or weight).
Whenever one dimension of context is changed or an attribute is added, all attributes of that dimension of context are "flushed", that is they need to be repeated in their entirety. For example, when the subject is changed from patient (name, id) to fetus (number), then the parameters of the patient are discarded. E.g., the patient's ID does not apply to the fetus.
"Extending" the same class and dimension of observation context isn't feasible, since one cannot "null out" or remove a previously set attribute. Any time a dimension of observation context is "replaced", any attributes that are unspecified remain unspecified (i.e., they are not inherited).
Table TID 1001. Observation Context
The observer (person or device) that created the Content Items to which this context applies.
Whenever this Template is invoked, all previously inherited attributes of Observer Context are discarded and replaced.
There may be more than one observer, as this Template may be invoked with a VM 1-n, and both person and device observers. In such a case, the Content Items of TID 1003 “Person Observer Identifying Attributes” and TID 1004 “Device Observer Identifying Attributes” shall be included in the order in which the values of Observer Type are specified. Since TID 1003 “Person Observer Identifying Attributes” and TID 1004 “Device Observer Identifying Attributes” both include a single mandatory Content Item as their first Content Item, which observer is being described can be determined
Table TID 1002. Observer Context
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Defaults to (121006, DCM, "Person") |
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IFF Row 1 value = (121006, DCM, "Person") or Row 1 is absent |
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IFF Row 1 value = (121007, DCM, "Device") |
This Template contains identifying (and optionally descriptive) attributes of persons that are observers.
Table TID 1003. Person Observer Identifying Attributes
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Defaults to Institution Name (0008,0080) of the General Equipment Module |
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EV (121010, DCM, "Person Observer's Role in the Organization") |
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EV (121011, DCM, "Person Observer's Role in this Procedure") |
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EV (128775, DCM, "Identifier within Person Observer's Role") |
This Template (derived from the DICOM General Equipment Module of PS3.3) contains identifying (and optionally descriptive) attributes of devices that are observers.
Table TID 1004. Device Observer Identifying Attributes
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Defaults to value of Station Name (0008,1010) in General Equipment Module |
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Defaults to value of Manufacturer (0008,0070) in General Equipment Module |
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Defaults to value of Manufacturer's Model Name (0008,1090) in General Equipment Module |
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Defaults to value of Device Serial Number (0018,1000) in General Equipment Module |
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EV (121017, DCM, "Device Observer Physical Location During Observation") |
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This Template contains identifying (and optionally descriptive) attributes of the procedure that is the source of evidence being interpreted.
Whenever this Template is invoked, all previously inherited attributes of Procedure Context are discarded and replaced.
If an observed digital image is identified by other than a DICOM UID, a Study Instance UID must be generated for the non-DICOM evidence. The same must be done to document interpretation of hard-copy radiographs generated outside of the scope of the DICOM system.
Table TID 1005. Procedure Context
This Template contains identifying (and optionally descriptive) attributes of the subject of the observation.
Subject context identifies (and optionally) describes the subject of the observation, whether it be a patient (human or animal), a fetus (human or animal), a specimen, or a device.
Table TID 1006. Subject Context
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DCID 271 “Observation Subject Class” Defaults to (121025, DCM, "Patient") |
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IFF Row 1 value = (121025, DCM, "Patient") or Row 1 is absent |
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IFF Row 1 value = (121026, DCM, "Fetus") |
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IFF Row 1 value = (121027, DCM, "Specimen") |
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IFF Row 1 value = (121192, DCM, "Device Subject") |
Identifies (and optionally describes) a patient who is the subject.
Table TID 1007. Subject Context, Patient
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Defaults to value of Patient's Name (0010,0010) in Patient Module |
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Defaults to value of Patient ID (0010,0020) in Patient Module |
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Defaults to value of Patient's Birth Date (0010,0030) in Patient Module |
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Defaults to value equivalent to Patient's Sex (0010,0040) in Patient Module |
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Defaults to value of Patient's Age (0010,1010) in Patient Study Module UNITS = DCID 7456 “Units of Measure for Age” |
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DCID 7454 “Animal Taxonomic Rank Values” Defaults to value of Patient Species Code Sequence (0010,2202) in Patient Module, or if absent, (L-85003, SRT, "homo sapiens"). |
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Defaults to value of Patient Breed Code Sequence (0010,2293) in Patient Module |
Identifies (and optionally describes) a fetus who is the subject.
Table TID 1008. Subject Context, Fetus
Identifies (and optionally describes) a specimen that is the subject.
Identifies (and optionally describes) a device that is the subject of observations.
Table TID 1010. Subject Context, Device
This Template describes a person participating in an activity as other than an observer or subject. E.g., for a dose report documenting an irradiating procedure, participants include the person administering the irradiation and the person authorizing the irradiation.
This Template is included with specific contextual parameters from a parent Template.
This Template describes a device participating in an activity as other than an observer or subject. E.g., for a dose report documenting an irradiating procedure, participants include the irradiating device.
This Template is included with specific contextual parameters from a parent Template.
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If no Device Procedure Role is provided, BCID 7445 “Device Participating Roles” may be used. |
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This may be used for the name by which the organization manages the device. |
Defines a mechanism for specifying a language, optionally with designation of the country in which that language applies.
For example, the French language could be specified unmodified, or French as written in France or Canada could be distinguished.
The language codes specified in CID 5000 “Languages” optionally allow the encoding of the country of language in the code value for the language. Encoding of the country of language in a separate subsidiary Concept Modifier Content Item is allowed for backward compatibility with previous editions of the Standard.
Defines a mechanism for specifying the language in which the value of the parent Content Item (only) is written. Does not specify the language of the Concept Name of the parent Content Item, nor of any other descendants of the parent Content Item.
The language codes specified in CID 5000 “Languages” optionally allow the encoding of the country of language in the code value for the language. Encoding of the country of language in a separate subsidiary Concept Modifier Content Item is allowed for backward compatibility with previous editions of the Standard.
Defines a mechanism for specifying the language in which the value and the Concept Name of the parent Content Item (only) is written. Does not specify the language of any other descendants of the parent Content Item.
The language codes specified in CID 5000 “Languages” optionally allow the encoding of the country of language in the code value for the language. Encoding of the country of language in a separate subsidiary Concept Modifier Content Item is allowed for backward compatibility with previous editions of the Standard.
Defines a mechanism for specifying the language in which the value and the Concept Name of the parent Content Item and any other descendants of the parent Content Item is written.
The language codes specified in CID 5000 “Languages” optionally allow the encoding of the country of language in the code value for the language. Encoding of the country of language in a separate subsidiary Concept Modifier Content Item is allowed for backward compatibility with previous editions of the Standard.
Table TID 1204. Language of Content Item and Descendants
Defines a mechanism for specifying one or more equivalent meanings for the Concept Name of the parent Content Item.
Table TID 1210. Equivalent Meaning(s) of Concept Name
A coded equivalent meaning for the Concept Name can also be included using the attribute Equivalent Code Sequence (0008,0121) in the Concept Name Code Sequence (0040,A043) (see Section 8.9 “Equivalent Code Sequence” in PS3.3 ), though the equivalent code(s) in the Equivalent Code Sequence (0008,0121) need not be the same as those in TID 1210.
Defines a mechanism for specifying one or more equivalent meanings for the Value of the parent Content Item.
Table TID 1211. Equivalent Meaning(s) of Value
For example, to describe a longer, more meaningful equivalent (in the same language) for a procedure code than is defined in a coding scheme:
CODE: (121023, DCM, "Procedure Code") = (50291CC, ICD10PCS, "IMAGING:CNS:CT:SELLA:LOWOSMOLAR:IT, U, E:2PLANE3D")
> HAS CONCEPT MOD TEXT: (121051, DCM, "Equivalent meaning of value") = "imaging study central nervous system of the sella turcica/pituitary gland with low osmolar contrast intrathecal, unenhanced and enhanced, in two planes with 3D reconstructions"
For example, to specify a concept name and value in both French and English in Canada:
CODE:(T-D0005, SRT, "Anatomical structure") = (T-04000, SRT, "Breast")
> HAS CONCEPT MOD CODE: (121048, DCM, "Language of name and value") = (en-CA, RFC3066, "English, Canada")
> HAS CONCEPT MOD CODE: (121050, DCM, "Equivalent meaning of concept name") = (T-D0005, SRT, " Structure de l'anatomie ")
>> HAS CONCEPT MOD CODE: (121047, DCM, " Langue de la valeur ") = (fr-CA, RFC3066, " Français, Canadien ")
> HAS CONCEPT MOD CODE: (121051, DCM, "Equivalent meaning of value") = (T-04000, SRT, " Sein ")
>> HAS CONCEPT MOD CODE: (121047, DCM, " Langue de la valeur ") = (fr-CA, RFC3066, " Français, Candie ")
3. A coded equivalent meaning for the Concept Value of a CODE Content Item can also be included using the attribute Equivalent Code Sequence (0008,0121) in the Concept Code Sequence (0040, A168) (see Section 8.9 “Equivalent Code Sequence” in PS3.3 ).
Concept Name Modifier for negation of the presence of a finding represented by a post-coordinated concept.
For example, negation modifier applied to "distention" in the post-coordinated structure:
CODE: "anatomic location" = "bile duct"
> HAS PROPERTY CODE: "morphology" = "distention"
The presence-negation modifier modifies the entire post-coordinated concept, not just the Source Content Item of the HAS CONCEPT MOD relationship. The entire branch of the tree from the Content Item is included in the post-coordinated structure that is negated.
Table TID 1401. Area Measurement
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UNITS = DCID 7461 “Units of Area Measurement” |
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IF concept name of Row 1 is (G-A16A, SRT, "Area of defined region"), and IFF Row 5 or 6 not present. |
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IF concept name of Row 1 is (G-A16A, SRT, "Area of defined region"), and IFF Row 2 or 6 not present. |
Reference shall be to a Segmentation Image, with a single value specified in Referenced Frame Number |
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IF concept name of Row 1 is (G-A16A, SRT, "Area of defined region"), and IFF Row 2 or 5 not present. |
Reference shall be to a Segmentation Image, with a single value specified in Referenced Frame Number |
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A Graphic Type of POINT implies that the object is a single pixel and the object's area is the area of the pixel. Otherwise the type shall be a closed POLYLINE (start and end point the same) or a CIRCLE or an ELLIPSE. |
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Referenced Frame Number (0008,1160) is an attribute of the IMAGE Content Item. If the Referenced Segmentation SOP Instance has Segmentation Type (0062,0001) value BINARY, it identifies the area of defined (measured) region by pixel values in the referenced frame with value 1. For Segmentation Type value FRACTIONAL, the area is computed by an implementation dependent method. Frame number shall be specified even if the Segmentation SOP Instance has only a single frame. |
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The values of (112039, DCM, "Tracking Identifier") and (112040, DCM, "Tracking Unique Identifier"), if present, shall match the corresponding values of Tracking ID (0062,0020) and Tracking UID (0062,0021), if present, in the corresponding Segment of any Segmentation instance referenced in Row 5. |
Table TID 1402. Volume Measurement
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The two dimensional perimeter of the volume's intersection with or projection into the image. A Graphic Type of POINT implies that the volume's intersection or projection in a plane is a single pixel. A single pixel projection perimeter cannot cause a volume calculation to become 0. Otherwise the type shall be a closed POLYLINE (start and end point the same) or a CIRCLE or an ELLIPSE. |
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Referenced Segment Number (0062,000B) is an attribute of the IMAGE Content Item. If the Referenced Segmentation SOP Instance has Segmentation Type (0062,0001) value BINARY, it identifies the defined (measured) volume by pixel/voxel values in the frames of the referenced segment with value 1. For Segmentation Type value FRACTIONAL, the volume is computed by an implementation dependent method. Segment number shall be specified even if the Segmentation SOP Instance has only a single segment. |
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The values of (112039, DCM, "Tracking Identifier") and (112040, DCM, "Tracking Unique Identifier"), if present, shall match the corresponding values of Tracking ID (0062,0020) and Tracking UID (0062,0021), if present, in the corresponding Segment of any Segmentation instance referenced in Row 5. |
This Template provides a general structure to report one or more measurements for some metric, e.g., density, flow, or concentration, over a planar region of interest in an image. The ROI may be specified by an SCOORD on an image, or by a Segmentation Image.
Table TID 1410. Parameters
Table TID 1410. Planar ROI Measurements
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Reference shall be to a Segmentation Image, with a single value specified in Referenced Frame Number, and with a single value specified in Referenced Segment Number |
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EV (126100, DCM, "Real World Value Map used for measurement") |
SOP Class UID shall be Real World Value Mapping Storage ("1.2.840.10008.5.1.4.1.1.67") |
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$TargetSiteMod = $TargetSiteMod $RangeAuthority = $RangeAuthority |
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This Template provides a general structure to report one or more measurements for some metric, e.g., density, flow, or concentration, over a volumetric region of interest in a set of images or a Frame of Reference. The volumetric ROI may be specified by a set of SCOORDs on an image set representing a volume, by a volumetric Segmentation Image, by a volume defined in a Surface Segmentation, or by a SCOORD3D.
Table TID 1411. Parameters
Table TID 1411. Volumetric ROI Measurements
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Reference shall be to a Segmentation Image or Surface Segmentation object, with a single value specified in Referenced Segment Number |
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EV (126100, DCM, "Real World Value Map used for measurement") |
SOP Class UID shall be Real World Value Mapping Storage ("1.2.840.10008.5.1.4.1.1.67") |
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$TargetSiteMod = $TargetSiteMod $RangeAuthority = $RangeAuthority |
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This Template encodes measurements for some metric, e.g., density, flow, or concentration.
Table TID 1419. Parameters
Table TID 1419. ROI Measurements
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EV (126100, DCM, "Real World Value Map used for measurement") |
SOP Class UID shall be Real World Value Mapping Storage ("1.2.840.10008.5.1.4.1.1.67") |
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This Template encodes measurements for some metric, e.g., density, flow, or concentration, which are acquired over some defined sampling (e.g., over successive time slots in a dynamic contrast enhanced acquisition).
Table TID 1420. Parameters
Table TID 1420. Measurements Derived From Multiple ROI Measurements
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DCID 7465 “Measurements Derived From Multiple ROI Measurements” |
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$TargetSiteMod = $TargetSiteMod $RangeAuthority = $RangeAuthority |
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$TargetSiteMod = $TargetSiteMod $RangeAuthority = $RangeAuthority |
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This Root Template encodes a list of Measurement Groups each containing lists of measurements, together with any derived measurements.
Each Measurement Group is identified by Tracking ID and UIDs.
An image library is available to describe characteristics of the images referenced by the measurements, if any.
Table TID 1500. Measurement Report
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$Measurement = BCID 7469 “Generic Intensity and Size Measurements” $Measurement = BCID 7468 “Texture Measurements” $Units = BCID 7181 “Abstract Multi-dimensional Image Model Component Units” $Derivation = BCID 7464 “General Region of Interest Measurement Modifiers” $Method = BCID 6147 “Response Criteria” |
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$Measurement = BCID 7469 “Generic Intensity and Size Measurements” $Measurement = BCID 7468 “Texture Measurements” $Units = BCID 7181 “Abstract Multi-dimensional Image Model Component Units” $Derivation = BCID 7464 “General Region of Interest Measurement Modifiers” $Method = BCID 6147 “Response Criteria” |
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$Measurement = BCID 7469 “Generic Intensity and Size Measurements” $Measurement = BCID 7468 “Texture Measurements” $Units = BCID 7181 “Abstract Multi-dimensional Image Model Component Units” $Derivation = BCID 7464 “General Region of Interest Measurement Modifiers” $Method = BCID 6147 “Response Criteria” |
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DTID 1420 “Measurements Derived From Multiple ROI Measurements” |
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This Template groups Measurements into a Measurement Group.
Each Measurement Group is identified by Tracking ID and UIDs, and may be described as having being made at a particular time point.
Measurement groups may contain various common measurement modifiers that are shared by all measurements in the group, such as method and finding site.
Table TID 1501. Parameters
Table TID 1501. Measurement Group
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EV (126100, DCM, "Real World Value Map used for measurement") |
SOP Class UID shall be Real World Value Mapping Storage ("1.2.840.10008.5.1.4.1.1.67") |
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$TargetSiteMod = $TargetSiteMod $RangeAuthority = $RangeAuthority |
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This Template describes information about the time point, for example, at which a measurement was obtained.
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Usually the same value as the Clinical Trial Time Point ID (0012,0050) attribute in the Clinical Trial Study Module, though not confined to clinical trial use. May or may not be human readable, and not required to be a DICOM UID. |
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All of the subjects within a treatment protocol that are examined at a particular scheduled time point (e.g., "baseline", "pre-treatment", "first post-treatment") will have the same Protocol Time Point Identifier, but different Subject Time Point Identifiers. However, in different protocols, the Protocol Time Point Identifiers for the same conceptual "time point" will be different. E.g., the "baseline" time point will have different Protocol Time Point Identifiers in different protocols. May or may not be human readable, and not required to be a DICOM UID. |
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Typically a short pre-defined label that has the same scope as Protocol Time Point Identifier (i.e., same conceptual time point within a treatment protocol) but is human-readable and understandable, e.g., "BASELINE" or "TP0", "TP1", etc. Usually the same value as Clinical Trial Time Point Description (0012,0051) attribute in the Clinical Trial Study Module, though not confined to clinical trial use. The Concept Name is selected as (C2348792, UMLS, "Time Point") (which is (C68568, NCIt, "Time Point"), defined as "a specific point in the time continuum, including those established relative to an event") in order to be compatible with external terminologies. |
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More than one type is permitted, e.g., a time point may be "posttreatment" as well as "unscheduled" or "nadir", etc. |
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The order is expected to be monotonically increasing within a particular scope of usage, but is not required to start at 0 or 1, nor required to increase in increments of 1 or even the same increment (e.g., to allow for retrospective insertion of unscheduled time points). In clinical usage, the Time Point Order would be expected to be temporally increasing, but in a clinical trial may be a randomized reading order rather than a temporal order. |
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Longitudinal temporal information may be inherited from Longitudinal Temporal Offset from Event (0012,0052) and Longitudinal Temporal Event Type (0012,0053) in the PS3.3 Section C.7.2.3 Clinical Trial Study Module, or may be specified or overridden within this template (e.g., if different measurements in the same SR Instance were measured on different time points). |
The Image Library contains references to images and selected attributes describing them that facilitate analysis without having to retrieve the entire set of referenced images.
Each instance of the Image Library Entry Template contains the Image SOP Class and Instance UIDs, and selected attributes for an image that facilitate analysis without having to retrieve the entire set of referenced images.
This Template contains selected attributes for an image or group of images. The descriptive information may be copied from images or derived.
Table TID 1602. Image Library Entry Descriptors
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The value of Anatomic Region Sequence (0008,2218) in the Image IOD, or a code derived from Body Part Examined (0018,0015) using the mapping described in Annex L. |
This Template contains selected attributes for a projection radiography image or group of such images. The descriptive information may be copied from images or derived.
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First (row) and second (column) components of Patient Orientation (0020,0020) in the Image IOD. See Section C.7.6.1.1.1 “Patient Orientation” in PS3.3 . |
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The second component of Imager Pixel Spacing (0018,1164) in the Image IOD. See Section C.8.11.4 “DX Detector Module” in PS3.3 . |
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The first component of Imager Pixel Spacing (0018,1164) in the Image IOD. See Section C.8.11.4 “DX Detector Module” in PS3.3 . |
This Template contains selected attributes for a cross-sectional image or group of such images. The descriptive information may be copied from images or derived.
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The second component of Pixel Spacing (0028,0030) in the Image IOD. See Section 10.7.1.1 “Pixel Spacing” in PS3.3 and Section C.7.6.2 “Image Plane Module” in PS3.3 . |
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The first component of Pixel Spacing (0028,0030) in the Image IOD. See Section 10.7.1.1 “Pixel Spacing” in PS3.3 and Section C.7.6.2 “Image Plane Module” in PS3.3 . |
This Template contains selected attributes for a CT image or group of such images. The descriptive information may be copied from images or derived.
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A code derived from the value of Acquisition Type (0018,9302) in the Image IOD. See Section C.8.15.3.2 “CT Acquisition Type Macro” in PS3.3 . |
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A code derived from the value of Reconstruction Algorithm (0018,9315) in the Image IOD. See Section C.8.15.3.7 “CT Reconstruction Macro” in PS3.3 . |
This Template contains selected attributes for a MR image or group of such images. The descriptive information may be copied from images or derived.
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The value of Pulse Sequence Name (0018,9005) or Sequence Name (0018,0024) in the Image IOD. See Section C.8.13.4 “MR Pulse Sequence Module” in PS3.3 . |
This Template contains selected attributes for a PET image or group of such images. The descriptive information may be copied from images or derived.
The content of this Template is similar to that in TID 15101 NM/PET Protocol Context, but is in the form of an SR Template rather than a Protocol Context Template, and the content items are not nested as modifiers. There is also some similarity to TID 3307 NM/PET Perfusion Measurement Group.
Table TID 1607. Image Library Entry Descriptors for PET
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The units for half life are chosen to be seconds, to match the units used for Radionuclide Half Life (0018,1075). See Section C.8.9.2 “PET Isotope Module” in PS3.3 . |
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In an earlier edition of the standard, an incorrect DCM code was used for this concept, which was already assigned as (109081, DCM, "Prospective gating"). |
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In an earlier edition of the standard, an incorrect DCM code was used for this concept, which was already assigned as (109082, DCM, "Retrospective gating"). |
Basic report Template for general diagnostic imaging interpretation reports.
Can only be instantiated at the root node and cannot be included in other Templates.
No Content Items other than those defined in Observation Context TID 1001 “Observation Context” may be the target of a HAS OBS CONTEXT relationship when TID 2000 “Basic Diagnostic Imaging Report” is invoked.
Individual numeric or image observations that may be useful for inclusion as individual findings or as the source of inferences in a report.
Table TID 2001. Basic Diagnostic Imaging Report Observations
The Report Narrative allows recording of text, code, and numeric observations. The order of Content Items in the Template is not significant; the order of Content Items in a SOP Instance may be significant to the narrative flow of the report.
Basic report Template for general diagnostic imaging interpretation reports produced in a dictation/transcription workflow. SR documents encoded using this Template are intended to be transformable to HL7 Clinical Document Architecture format (see Section X.3 “Transcribed Diagnostic Imaging CDA Instance Content” in PS3.17 and Annexes in PS3.20).
This Template can be instantiated only at the root node, and cannot be included in other Templates.
Observation Context shall be inherited from outside the SR Content tree, and shall not be changed within the Content tree. To satisfy the requirement that Observer Context is inherited, either or both the Author Observer Sequence (0040,A078) or the Verifying Observer Sequence (0040,A073) from the SR Document Module must be present in the SOP Instance.
Table TID 2005. Transcribed Diagnostic Imaging Report
This Template is used for general imaging reports for both radiation producing and non-radiation producing modalities.
For radiation producing modalities, radiation exposure and protection information is required, such as to support nationally-specific legal or standard requirements.
It contains mandatory sections, each of which may appear only once in objects instantiated from the Template, including the medical content of the report that comprises relevant medical history data, information on the current request (i.e., clinical question that is expected to be answered by the requested procedure), impressions on the current imaging procedure that has been performed, and radiation exposure and protection information.
This Template is a specialization of TID 2000 “Basic Diagnostic Imaging Report”, in that it uses the same structure of headings and content, but mandates the presence and order of specific headings, and extends the subordinate content with specific Content Items.
Table TID 2006. Imaging Report With Conditional Radiation Exposure and Protection Information
No Content Items other than those defined in TID 1001 “Observation Context” may be the target of a HAS OBS CONTEXT relationship when TID 2006 “Imaging Report With Conditional Radiation Exposure and Protection Information” is invoked.
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Even though this information is related to the content of Row 6 in TID 2007 “Imaging Procedure Description”, it is present here for consistency with other report Templates. |
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Information on at least one of the following person observers is mandatory: (For those person observers, requirement types as specified in TID 1003 “Person Observer Identifying Attributes” apply. That means that "Person Observer Name" is the only mandatory attribute). |
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Each heading (concept code from CID 7001 “Diagnostic Imaging Report Headings”) may appear only once, and may not repeat the headings (concept codes) used when instantiating any other rows of this Template. |
Contains information related to the procedure.
Table TID 2007. Imaging Procedure Description
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DCID 4028 “Craniofacial Anatomic Regions” |
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Shall be equal to the Study Date (0020,0020) in the General Study Module in the images to which this report applies. |
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If present, shall be equal to the Study Time (0020,0030) in the General Study Module in the images to which this report applies. |
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Contains information related to the radiation exposure and protection of the patient, as is required by national legal requirements or standards.
Other information about the current procedure is described in TID 2006 “Imaging Report With Conditional Radiation Exposure and Protection Information” and not repeated here.
Table TID 2008. Radiation Exposure and Protection Information
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EV (73569-6, LN, "Radiation Exposure and Protection Information") |
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IFF ionizing radiation is applied in the context of the current procedure |
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EV (440252007, SCT, "Administration of radiopharmaceutical") |
IFF radioactive substance is administered in the context of the current procedure |
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The clinician responsible for determining that the irradiating procedure was appropriate for the indications. |
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A textual, human-readable description of the radiation exposure is all that is required by this Template (such as is sufficient to comply with, for example, German law). Detailed specification of exposure is out of the scope of this Template. Such information may be given in a separate SR instances such as described in TID 10001 “Projection X-Ray Radiation Dose” or TID 10011 “CT Radiation Dose”, and referenced from TID 2007 “Imaging Procedure Description”. |
The Key Object Selection Template is intended for flagging one or more significant images, waveforms, or other composite SOP Instances. Key Object Selection contains:
For instance, when this Template is used to identify images rejected for quality reasons, the device or person performing the quality assessment is identified in observation context items (invoked through TID 1002 “Observer Context”). The reason for rejection can be included both as a code used as a concept modifier for the document title, and as text description.
The order of object references may be significant, e.g., when the title concept is "For Conference".
Instances referenced in a Key Object Selection Document may be securely referenced by Digital Signature or MAC mechanisms within the SR Document General Module (see PS3.3).
The Template can only be instantiated at the root node and cannot be included in other Templates. The Template is not extensible; that is, no other Content Items may be added to this Template, or the Templates that are included, recursively.
Table TID 2010. Key Object Selection
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IF Row 1 Concept Name = (113001, DCM, "Rejected for Quality Reasons") or (113010, DCM, "Quality Issue") |
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IF Row 1 Concept Name = (113013, DCM, "Best In Set") |
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The Spectacle Prescription Report is a structured report used to represent the prescription for a patient. Usually a prescription is for both eyes, but sometimes just one. The Spectacle Prescription Report defines a refractive correction relative to which visual acuity may be measured subjectively, and thus may be referenced by a Visual Acuity Measurements Storage SOP Instance.
The Macular Grid Thickness and Volume Report is a structured report encoding the macular grid thickness and volume values derived from ophthalmic images, such as ophthalmic OPT images. This may encode measurements of either or both eyes.
The macular grid conveyed by this report is based upon the grid employed by the Early Treatment of Diabetic Retinopathy Study (ETDRS) to measure area and proximity of macular edema to the anatomic center (fovea) of the macula. See ETDRS Report Number 10.
Table TID 2100. Macular Grid Thickness and Volume Report
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EV (111690, DCM, "Macular Grid Thickness and Volume Report") |
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$Laterality = EV (G-A100, SRT, "Right") |
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$Laterality = EV (G-A101, SRT, "Left") |
This Template encodes the macular grid thickness and volume measurements for a single eye.
Table TID 2101. Macular Grid Thickness and Volume Measurement
This Template specifies the algorithm (and parameters) used to create a quality rating for an image or image set.
It is expected that the identified algorithm will create a consistent quality rating when analyzing a given image. If the algorithm allows change to its parameters that would alter the quality rating created, the specific parameters used should be specified.
| DICOM PS3.16 2018a - Content Mapping Resource |
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