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

8.2 Imaging Header (Current)
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## 8.2 Imaging Header

Template ID | 1.2.840.10008.9.21
Name | Imaging Header Elements
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | CDA Header Elements for imaging reports, including encounter, order, and study context
Classification | CDA Header Elements
Relationships | Included in 7.1 Imaging Report
Context | sibling 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
--- | --- | --- | --- | --- | --- | --- | --- | ---
|  | template​Id | 1..1 | SHALL | II |  |  |
| @ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.21 |
|  | component​Of | 1..1 | SHALL |  |  |  |
| > | encompassing​Encounter | 1..1 | SHALL |  |  |  |
| >> | id | 0..1 | SHOULD | II |  |  |
Encounter​IDIssuer | >>@ | @root | 1..1 | SHALL | UID |  | Issuer of Admission ID Sequence (0038;0014) > Universal Entity ID (0040,0032) Visit Number PV1-19.4.2 |
Encounter​ID | >>@ | @extension | 1..1 | SHALL | ST |  | Admission Id (0038,0010) Visit Number PV1-19.1 |
Encounter​Time | >> | effective​Time | 1..1 | SHALL |  |  |  |
| >> | location | 0..1 | MAY |  |  |  |
| >>> | health​Care​Facility | 1..1 | SHALL |  |  |  |
| >>>> | location | 0..1 | SHOULD |  |  |  |
Healthcare​Facility​Name | >>>>> | name | 1..1 | SHALL | EN |  |  |
Healthcare​Facility​Address | >>>>> | addr | 1..1 | SHALL | AD |  |  |
| >>>> | service​Provider​Organization | 0..1 | SHOULD |  |  |  |
Healthcare​Provider​Organization​Name | >>>>> | name | 1..1 | SHALL | ON |  |  |
| >> | encounter​Participant | 0..* | MAY |  |  |  |
| >>@ | @typeCode | 1..1 | SHALL |  |  | ATND |
| >>> | assigned​Entity | 1..1 | SHALL |  |  |  |
| >>>> | assigned​Person | 1..1 | SHALL |  |  |  |
Attending​Physician​Name | >>>>> | name | 1..1 | SHALL | EN |  |  |
|  | in​Fulfillment​Of | 1..* | SHALL |  |  |  |
Order[*] | > | order | 1..1 | SHALL |  |  |  |
| >> | id | 1..1 | SHALL | II |  |  |
Order​Assigning​Authority | >>@ | @root | 1..1 | SHALL | UID |  | Order Placer Identifier Sequence (0040,0026) > Universal Entity ID (0040,0032) Placer Order Number OBR-2.3 |
Order​Placer​Number | >>@ | @extension | 1..1 | SHALL | ST |  | Placer Order Number/Imaging Service Request (0040,2016) Placer Order Number OBR-2.1 |
| >> | ps3-20:accessionNumber | 1..1 | SHALL | II |  |  |
Accession​Assigning​Authority | >>@ | @root | 1..1 | SHALL | UID |  | Issuer of Accession Number Sequence (0008,0051) > Universal Entity ID (0040,0032) Filler Order Number OBR-2.3 |
Accession​Number | >>@ | @extension | 1..1 | SHALL | ST |  | Accession Number (0008,0050) Filler Order Number OBR-2.1 |
Ordered​Procedure​Code | >> | code | 0..1 | SHOULD | CE |  | Requested Procedure Code Sequence (0032,1064) Universal Service ID OBR-4 |
Order​Priority | >> | priority​Code | 0..1 | SHOULD | CE |  | ValueSet ActPriority Value Set 2.16.840.1.113883.11.16866 |
|  | documentation​Of | 1..* | SHALL |  |  |  |
Study[*] | > | service​Event | 1..1 | SHALL |  |  |  |
Study​UID | >> | id | 1..1 | SHALL | II |  | Study Instance UID (0020,000D) Study Instance UID IPC-3 |
Procedure​Code | >> | code | 1..1 | SHALL | CE |  | Procedure Code Sequence (0008,1032) |
Modality | >>> | translation | 1..* | SHALL | CD | SHALL CNE | Modality (0008,0060) |
Anatomic​Region​Code | >>> | translation | 0..1 | SHOULD | CD |  | Concept​Domain AnatomicRegion |
| >> | effective​Time | 1..1 | SHALL | IVL <TS> |  |  |
Study​Time | >>> | low | 1..1 | SHALL | TS |  | Study Date (0008,0020) + Study Time (0008,0030) + Timezone Offset From UTC (0008,0201) Observation Date/Time OBR-7 |
Performer[*] | >> | performer | 0..* | MAY |  |  |  |
Type | >>@ | @typeCode | 1..1 | SHALL | CS | SHALL | ValueSet x_serviceEventPerformer Value Set 2.16.840.1.113883.11.19601 |
| >>> | assigned​Entity | 1..1 | SHALL |  |  |  |
ID | >>>> | id | 1..1 | SHALL | II |  |  |
| >>>> | assigned​Person | 1..1 | SHALL |  |  |  |
Name | >>>>> | name | 1..1 | SHALL | PN |  |  |
|  | participant | 1..1 | SHALL |  |  |  |
| @ | @typeCode | 1..1 | SHALL | CS | SHALL | REF |
| > | associated​Entity | 1..1 | SHALL |  |  |  |
| >@ | @classCode | 1..1 | SHALL | CS | SHALL | PROV |
Referrer​ID | >> | id | 0..1 | SHOULD | II |  | Ordering Provider ORC-12.1 + ORC-12.9.2 |
Referrer​Addr | >> | addr | 0.* | SHOULD | AD |  | Ordering Provider Address ORC-24 |
Referrer​Tel | >> | telecom | 0..* | SHOULD | TEL |  | Call Back Phone Number ORC-14 |
| >> | associated​Person | 1..1 | SHALL |  |  |  |
Referrer​Name | >>> | name | 1..1 | SHALL | PN |  | Referring Physician's Name (0008,0090) Ordering Provider ORC-12 |
|  | data​Enterer | 0..1 | MAY |  |  |  |
| @ | @typeCode | 1..1 | SHALL | CS | SHALL | ENT |
| > | assigned​Entity | 1..1 | SHALL |  |  |  |
Transcriptionist​ID | >> | id | 0..1 | SHOULD | II |  | Transcriptionist OBR-35.1.1 |
| >> | assigned​Person | 0..1 | SHOULD |  |  |  |
Transcriptionist​Name | >>> | name | 1..1 | SHALL | PN |  | Transcriptionist OBR-35.1 |

Note that there is no business name associated with this template. Rather, this template is an editorial convenience for template specification, and the Business Names for the elements of this template are logically part of the Business Name scope of the invoking template.

### 8.2.1 componentOf/encompassingEncounter

The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, Visit Number, or Admission ID, equivalent to DICOM attribute (0038,0010), that number should be present as the ID of the encompassingEncounter.

The effectiveTime of the encompassingEncounter represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.

Example 8.2.1-1. componentOf example

    <componentOf>
        <encompassingEncounter>
            <id extension="9937012" root="1.3.6.4.1.4.1.2835.12"/>
            <effectiveTime value="20060828170821"/>
            <encounterParticipant typeCode="ATND">
                <assignedEntity>
                    <id extension="4" root="2.16.840.1.113883.19"/>
                    <code code="208M00000X"
                        codeSystem="2.16.840.1.113883.6.101"
                        codeSystemName="NUCC"
                        displayName="Hospitalist"/>
                    <addr nullFlavor="NI"/>
                    <telecom nullFlavor="NI"/>
                    <assignedPerson>
                        <name>
                            <prefix>Dr.</prefix>
                            <given>Fay </given>
                            <family>Family</family>
                        </name>
                    </assignedPerson>
                </assignedEntity>
            </encounterParticipant>
        </encompassingEncounter>
    </componentOf>

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