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

5.3.3 Unknown Information (Current)
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### 5.3.3 Unknown Information

If a document creator wants to state that a piece of information is unknown, the following principles apply:

1. If the creator doesn't know an attribute of an act, that attribute can be null.

   Example 5.3.3-1. Unknown medication example

       <text>patient was given a medication but I do not know what it was</text>
       <entry>
           <substanceAdministration moodCode="EVN" classCode="SBADM">
               <consumable>
                   <manufacturedProduct>
                       <manufacturedLabeledDrug>
                           <code nullFlavor="NI"/>
                       </manufacturedLabeledDrug>
                   </manufacturedProduct>
               </consumable>
           </substanceAdministration>
       </entry>

2. If the creator doesn't know if an act occurred, the nullFlavor is on the act (detail could include specific allergy, drug, etc.).

   Example 5.3.3-2. Unknown medication use of anticoagulant drug example

       <text>I do not know whether or not patient received an anticoagulant drug</text>
       <entry></para>
           <substanceAdministration moodCode="EVN" classCode="SBADM" nullFlavor="NI">
               <consumable>
                   <manufacturedProduct>
                       <manufacturedLabeledDrug>
                           <code code="81839001" displayName="anticoagulant drug"
                               codeSystem="2.16.840.1.113883.6.96"
                               codeSystemName="SNOMED CT"/>
                       </manufacturedLabeledDrug>
                   </manufacturedProduct>
               </consumable>
           </substanceAdministration>
       </entry>

3. If the sender wants to state 'no known', a negationInd can be used on the corresponding act (substanceAdministration, Procedure, etc.)

   Example 5.3.3-3. No known medications example

       <text>No known medications</text>
       <entry>
           <substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
               <consumable>
                   <manufacturedProduct>
                       <manufacturedLabeledDrug>
                           <code code="410942007" displayName="drug or medication"
                               codeSystem="2.16.840.1.113883.6.96"
                               codeSystemName="SNOMED CT"/>
                       </manufacturedLabeledDrug>
                   </manufacturedProduct>
               </consumable>
           </substanceAdministration>
       </entry>

Other CDA implementation guides recommended using specific codes to assert no known content, for example SNOMED CT 160244002 "No known allergies" or 160245001 "No current problems or disability". Specific codes are still allowed; however, use of negationInd is an alternative, and the specific approach for each use will be specified in the associated template.

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