DICOM PS3.20 2018d - Imaging Reports using HL7 Clinical Document Architecture

9.8.4 Complications (Current)
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### 9.8.4 Complications

Template ID | 2.16.840.1.113883.​10.20.22.2.37
Name | Complications
Effective Date | 2012-07
Version Label | DICOM-20150324
Status | Active
Description | The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.
Classification | CDA Section Level
Relationships | Included in 9.3 Imaging Procedure Description
Context | parent node
Open/Closed | Open
Revision History | From Consolidated CDA r1.1 DICOM-20150324: Addition of optional entries

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
Complications |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 2.16.840.1.113883.​10.20.22.2.37 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (55109-3, LOINC, "Complications") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > | entry | 0..* | MAY |  |  |  |
Coded​Observation[*] | >> | observation |  |  |  |  |  | 10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

Example 9.8.4-1. Complications section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.2.37"/>
        <id root="1.2.840.10213.2.62.70444786655528.11428987524546666"/>
        <code code="55109-3"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC"
            displayName="Complications"/>
        <title>Complications</title>
        <text>Immediately following IV contrast injection, the patient reporting itching "all over".
            Dr. Smith examined the patient and found multiple urticaria. The patient denied difficulty
            breathing or swallowing. The patient was given Benadryl 50 mg PO and was followed for
            30 minutes, during which time the symptoms subsided.</text>
        <entry>
            <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.6.2.13"/>
                <!-- Coded Observation -->
                ...
            </observation>
        </entry>
    </section>

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9.8.3 Medical (General) History | Home | 9.8.5 Radiation Exposure and Protection Information

DICOM PS3.20 2018d - Imaging Reports using HL7 Clinical Document Architecture