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

9.8.2 Procedure Indications (Current)
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### 9.8.2 Procedure Indications

Template ID | 2.16.840.1.113883.​10.20.22.2.29
Name | Procedure Indications
Effective Date | 2012-07
Version Label | DICOM-20150324
Status | Active
Description | Records details about the reason for the procedure. This section may include the pre-procedure diagnosis or diagnoses as well as one or more symptoms that contribute to the reason the procedure is being performed.
Classification | CDA Section Level
Relationships | Included in 9.2 Clinical Information
Context | parent node
Open/Closed | Open
Revision History | From Consolidated CDA r1.1 DICOM-20150324: adapted to use optional Coded Observation entry rather than optional Indication entry

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
Procedure​Indications |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 2.16.840.1.113883.​10.20.22.2.29 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (59768-2, LOINC, "Procedure Indications") |
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 | 1..1 | SHALL |  |  | See 9.8.2.1 entry/observation | 10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

#### 9.8.2.1 entry/observation

The binding to the Coded Observation concept domains is:

Concept Domain or Element | Value Conf | Value
--- | --- | ---
Observation​Type | SHOULD | (432678004, SNOMED, "Indication for procedure")
Other concept domains |  | unspecified

### Note

In Consolidated CDA r1.1 the binding to the observationType is to Value Set Problem Type (2.16.840.1.113883.3.88.12.3221.7.2) with conformance SHOULD. Values from that Value Set are acceptable here as well.

Example 9.8.2.1-1. Procedure indications section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.2.29"/>
        <id root="1.2.840.10213.2.62.044785528.1142895426"/>
        <code code="59768-2"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC"
            displayName="Procedure Indications"/>
        <title>Procedure Indications</title>
        <text>The procedure is performed as a follow-up for abnormal screening result.</text>
    </section>

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