DICOM PS3.17 2018d - Explanatory Information

X.3 Transcribed Diagnostic Imaging CDA Instance Content (Current)
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## X.3 Transcribed Diagnostic Imaging CDA Instance Content

This section describes the use of transcribed dictation and Key Object Selection (KO) documents to produce an HL7 Clinical Document Architecture (CDA) Release 2 document.

### Note

While this section describes encoding as CDA Release 2, notes are provided about encoding issues for CDA Release 1.

### X.3.1 CDA Header Content

The header of the CDA instance includes:

- Identity of the patient ("recordTarget" participation)

- Identity of the requested procedure ("documentationOf" act relationship)

- Identity of the dictating physician ("author" participation)

- Identity of the transcriptionist ("dataEnterer" participation)

- Identity of the report signing physician ("legalAuthenticator" participation)

- Identity of the institution owning the report ("custodian" participation)

- Identity of the request/order ("inFulfillmentOf" act relationship)

### Note

The markup components in CDA Release 1 use different names.

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DICOM PS3.17 2018d - Explanatory Information