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

9.8.11 Recommendation (Current)
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### 9.8.11 Recommendation

Template ID | 1.2.840.10008.9.12
Name | Recommendation
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | This section provides a separate section to describe the study interpreter's recommendations for follow-up studies or procedures.
Classification | CDA Section Level
Relationships | Included in 9.6 Impression
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Recommendation |  | section |  |  |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.12 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (18783-1, LOINC, "Study recommendation") |
Title | > | title | 0..1 | MAY | ST |  |  |
Text | > | text | 0..1 | SHALL | ED |  |  |
Content[*] | >> | content | 0..* | SHALL | ST |  | [See 9.8.11.1 text/content] |
* | >>@ | @ID | 1..1 | SHALL | XML ID |  |  |
Guideline​Ref | >>> | link​Html | 0..1 | MAY | ST |  |  |
Guideline​URI | >>>@ | @href | 1..1 | SHALL | URI |  |  |
| > | entry | 0..* | SHOULD |  |  |  |
Followup​Procedure[*] | >> | procedure | 1..1 | SHALL |  |  |  |
| >>@ | @classCode | 1..1 | SHALL | CS | SHALL | PROC |
| >>@ | @moodCode | 1..1 | SHALL | CS | SHALL | PRP |
Procedure​Code | >>> | code | 1..1 | SHALL | CD |  | Concept​Domain Recommended Follow-up |
When | >>> | effective​Time | 1..1 | SHOULD | IVL <TS> |  |  |
| >>> | text | 1..1 | SHALL | ED |  |  |
Ref | >>>> | reference | 1..1 | SHALL | URL (XML IDREF) |  | # content​Ref |

#### 9.8.11.1 text/content

Each documented recommendation SHALL be included as narrative in a content element, labeled with an XML ID (see Section 9.1.1.1 <content> Markup and Links From Entries). The content element NEED NOT be top level markup within the section/text element; it MAY be wrapped in another allowed narrative block markup, such as paragraph, list/item, or table/row/cell.

If the recommendation is based on a clinical guideline, a reference to that guideline MAY be included in a linkHtml element.

Each recommendation SHOULD have a corresponding structured entry.

Example 9.8.11-1. Radiology recommendation section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="1.2.840.10008.9.12" />
        <id root="1.2.840.10213.2.62.7044779.114265201"/>
        <code code="18783-1" codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" displayName="Study Recommendation"/>
        <title>Radiology Recommendation</title>
        <text>
            <content ID="rec01">Biopsy should be considered. Follow-up at 3 month interval.
            </content>
            <linkHtml href="http://pubs.rsna.org/doi/abs/10.1148/radiol.2372041887"/>
        </text>
        <entry>
            <procedure ID="RadRec1" classCode="PROC" moodCode="PRP"/>
            <!-- local coding scheme -->
            <code code="9191919" codeSystem="2.16.840.1.56789.6.1"
                codeSystemName="My Hospital Coding System"
                displayName="3 month follow-up"/>
            <text><reference value="#rec01"/></text>
            <effectiveTime value="20141213"/>
        </entry>
    </section>

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