DICOM PS3.20 2019a - Imaging Reports using HL7 Clinical Document Architecture

9.6 Impression (Current)
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## 9.6 Impression

Template ID | 1.2.840.10008.9.5
Name | Impression
Effective Date | 2015/03/24
Version Label | DICOM-20150324
Status | Active
Description | The most important diagnoses or other clinical conclusions that can be made from the imaging observations and other clinical information are recorded here. This section may include recommendations for additional imaging tests or other actions, as well as global assessments, such as BI-RADS Categories or the equivalent.
Classification | CDA Section Level
Relationships | Included in 7.1 Imaging Report
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
--- | --- | --- | --- | --- | --- | --- | --- | ---
Impression |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 1.2.840.10008.9.5 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (19005-8, LOINC, "Impressions") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > | component | 0..1 | MAY |  |  |  |
Communication​Of​Actionable​Findings | >> | section | 1..1 | SHALL |  |  |  | 9.8.10 Communication of Actionable Findings 1.2.840.10008.9.11
| > | component | 0..1 | MAY |  |  |  |
Key​Images | >> | section | 1..1 | SHALL |  |  |  | 9.8.6 Key Images 1.3.6.1.4.1.19376.​1.4.1.2.14
| > | component | 0..* | MAY |  |  |  |
Recommendation | >> | section | 1..1 | SHALL |  |  |  | 9.8.11 Recommendation 1.2.840.10008.9.12
| > | entry | 0..* | MAY |  |  |  |
Coded​Observation | >> | observation | 1..1 | SHALL | CD |  |  | 10.1 Coded Observation 2.16.840.1.113883.​10.20.6.2.13

Example 9.6-1. Impression section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.2.27"/>
        <id root="1.2.840.10213.2.62.994948294044785528.11422458954285205"/>
        <code code="19005-8"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC"
            displayName="Impressions"/>
        <title>Impression</title>
        <text>This exam identified ...</text>
        <!-- other sections and entries here -->
    </section>

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DICOM PS3.20 2019a - Imaging Reports using HL7 Clinical Document Architecture