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

C.5.2 Transcoded HL7 CDA Release 2 Imaging Report (Current)
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### C.5.2 Transcoded HL7 CDA Release 2 Imaging Report

    <?xml version="1.0" encoding="utf-8"?>
    <?xml-stylesheet type="text/xsl" href="CDA-DIR.xsl"?>
    <ClinicalDocument xmlns="urn:hl7-org:v3"
            xmlns:voc="urn:hl7-org:v3/voc"
            xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
            xmlns:ps3-20="urn:dicom-org:ps3-20"
            xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
        <realmCode code="UV"/>
        <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
        <templateId root="1.2.840.10008.9.1"/>
        <templateId root="1.2.840.10008.9.20"/>
        <templateId root="1.2.840.10008.9.21"/>
        <templateId root="1.2.840.10008.9.22"/>
        <id root="1.2.840.113619.2.62.994044785528.12"extension="20060828170821659"/>
        <code code="18748-4" codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC" displayName="Diagnostic Imaging Report"/>
        <title>Chest X-Ray, PA and LAT View</title>
        <effectiveTime value="20060828170821"/>
        <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
        <languageCode code="en-US"/>
        <recordTarget>
            <patientRole>
                <id root="1.2.840.113619.2.62.994044785528.10" extension="0000680029"/>
                <addr nullFlavor="NI"/>
                <telecom nullFlavor="NI"/>
                <patient>
                    <name>
                        <given>John</given>
                        <family>Doe</family>
                    </name>
                    <administrativeGenderCode codeSystem="2.16.840.1.113883.5.1"code="M"/>
                    <birthTime value="19641128"/>
                </patient>
            </patientRole>
        </recordTarget>
        <author>
            <time value="20060823224352"/>
            <assignedAuthor>
                <id extension="121008" root="2.16.840.1.113883.19.5"/>
                <addr nullFlavor="NI"/>
                <telecom nullFlavor="NI"/>
                <assignedPerson>
                    <name>
                        <given>Richard</given>
                        <family>Blitz</family>
                        <suffix>MD</suffix>
                    </name>
                </assignedPerson>
            </assignedAuthor>
        </author>
        <custodian>
            <!-- custodian values have been added based on organizational policy (int his
             case they are not mapped from the SR sample document) -->
            <assignedCustodian>
                <representedCustodianOrganization>
                    <id root="2.16.840.1.113883.19.5"/>
                    <name>World University Hospital</name>
                    <telecom nullFlavor="NI"/>
                    <addr nullFlavor="NI"/>
                </representedCustodianOrganization>
            </assignedCustodian>
        </custodian>
        <!-- legal authenticator present in sample, document is VERIFIED -->
        <legalAuthenticator>
            <time value="20060827141500"/>
            <!-- Verification DateTime (0040,A030) -->
            <signatureCode code="S"/>
            <assignedEntity>
                <id extension="08150000" root="1.2.840.113619.2.62.994044785528.33"/>
                <addr nullFlavor="NI"/>
                <telecom nullFlavor="NI"/>
                <assignedPerson>
                    <name>
                        <given>Richard</given>
                        <family>Blitz</family>
                        <suffix>MD</suffix>
                    </name>
                </assignedPerson>
            </assignedEntity>
        </legalAuthenticator>
        <!-- Mapped from Referring Physician's Name (0008,0090) SR sample document -->
        <participant typeCode="REF">
            <associatedEntity classCode="PROV">
                <id nullFlavor="NI"/>
                <addr nullFlavor="NI"/>
                <telecom nullFlavor="NI"/>
                <associatedPerson>
                    <name>
                        <given>John</given>
                        <family>Smith</family>
                        <suffix>MD</suffix>
                    </name>
                </associatedPerson>
            </associatedEntity>
        </participant>
        <inFulfillmentOf>
            <order>
                <id extension="123451" root="1.2.840.113619.2.62.994044785528.29"/>
                <ps3-20:accessionNumber extension="10523475"root="1.2.840.113619.2.62.994044785528.27"/>
            </order>
        </inFulfillmentOf>
        <documentationOf>
            <serviceEvent classCode="ACT">
                <id root="1.2.840.113619.2.62.994044785528.114289542805"/>
                <!-- Study Instance UID -->
                <code code="11123" codeSystem="1.2.840.113619.2.62.5661"
                    codeSystemName="99WUHID" displayName="X-Ray Study"/>
                <translation code="XR" displayName="XR"
                    codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/>
                <translation code="51185008" displayName="Chest"
                    codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                <!-- anatomy code mapped from old style SNOMED in SR to new -->
            </code>
        </code>
        <effectiveTime>
            <low value="20060823222400"/>
        </effectiveTime>
    </serviceEvent>
    </documentationOf>
    <!-- transformation of a DICOM SR -->
    <relatedDocument typeCode="XFRM">
        <parentDocument>
            <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9"/>
            <!-- SOP Instance UID (0008,0018) of SR sample document-->
        </parentDocument>
    </relatedDocument>
    <component>
        <structuredBody>
            <component>
                <!--**************** Clinical Information Section *****************-->
                <section>
                    <templateId root="1.2.840.10008.9.2"/>
                    <code code="55752-0" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Clinical Information"/>
                    <title>Clinical Information</title>
                    <component>
                        <!--**************** Procedure Indications Subsection *****************
                            Section text mapped from "Reason for the Requested Procedure" (0040,1002)
                            within the Referenced Request Sequence (0040,A370) of the SR header, under
                            the assumption that the header attribute value has been displayed to, and
                            accepted by, the legal authenticator.-->
                        <section>
                            <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>Indications for Procedure</title>
                            <text>Suspected lung tumor</text>
                        </section>
                        <!--**************** End of Procedure Indications Subsection *****************-->
                    </component>
                    <component>
                        <!--**************** History Subsection *****************-->
                        <section>
                            <templateId root="2.16.840.1.113883.10.20.22.2.39"/>
                            <id root="1.2.840.10213.2.62.7044785528.114289875"/>
                            <code code="11329-0" codeSystem="2.16.840.1.113883.6.1"
                            codeSystemName="LOINC" displayName="History General"/>
                            <title>History</title>
                            <text>
                                <paragraph>
                                    <caption>History</caption>
                                    <content ID="Fndng1">Sore throat.</content>
                                </paragraph>
                            </text>
                            <entry>
                                <!-- History report element (TEXT) -->
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.6.2.12"/>
                                    <code code="121060" codeSystem="1.2.840.10008.2.16.4"
                                        codeSystemName="DCM" displayName="History"/>
                                    <value xsi:type="ED">
                                        <reference value="#Fndng1"/>
                                    </value>
                                </observation>
                            </entry>
                        </section>
                        <!--**************** End of History Subsection *****************-->
                    </component>
                    <!--**************** End of Clinical Information Section *****************-->
                </component>
                <component>
                    <!--**************** Imaging Procedure Description Section *****************-->
                    <section classCode="DOCSECT" moodCode="EVN">
                        <templateId root="1.2.840.10008.9.3"/>
                        <id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/>
                        <code code="55111-9" codeSystem="2.16.840.1.113883.6.1"
                        codeSystemName="LOINC" displayName="Current Imaging Procedure Description"/>
                        <title>Imaging Procedure Description</title>
                        <text> </text>
                        <entry>
                            <procedure moodCode="EVN" classCode="PROC">
                                <templateId root="1.2.840.10008.9.14"/>
                                <id root="1.2.840.6544.33.9100653988998717.997527582345600170"/>
                                <code code="11123" displayName="X-Ray Study"
                                codeSystem="1.2.840.113619.2.62.5661" codeSystemName="99WUHID"/>
                                <effectiveTime value="20060823222400"/>
                                <methodCode code="XR" displayName="XR"
                                codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"/>
                                <targetSiteCode code="51185008" displayName="Chest"
                                codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                            </procedure>
                        </entry>
                        <component>
                            <!--**************** DICOM Object Catalog Sub-section *****************-->
                            <section classCode="DOCSECT" moodCode="EVN">
                                <templateId root="2.16.840.1.113883.10.20.6.1.1"/>
                                <code code="121181" codeSystem="1.2.840.10008.2.16.4"
                                    codeSystemName="DCM" displayName="DICOM Object Catalog"/>
                                <entry>
                                    <!--**************** Study *****************-->
                                    <act classCode="ACT" moodCode="EVN">
                                        <templateId root="2.16.840.1.113883.10.20.6.2.6"/>
                                        <id root="1.2.840.113619.2.62.994044785528.114289542805"/>
                                        <code code="113014" codeSystem="1.2.840.10008.2.16.4"
                                            codeSystemName="DCM" displayName="Study"/>
                                        <!--**************** Series (Parent SR Document) *****************-->
                                        <entryRelationship typeCode="COMP">
                                            <act classCode="ACT" moodCode="EVN">
                                                <id root="1.2.840.113619.2.62.994044785528.20060823222132232023"/>
                                                <code code="113015" codeSystem="1.2.840.10008.2.16.4"
                                                        codeSystemName="DCM" displayName="Series">
                                                    <qualifier>
                                                        <name code="121139" codeSystem="1.2.840.10008.2.16.4"
                                                            codeSystemName="DCM" displayName="Modality">
                                                        </name>
                                                        <value code="CR" codeSystem="1.2.840.10008.2.16.4"
                                                            codeSystemName="DCM" displayName="SR Document">
                                                        </value>
                                                    </qualifier>
                                                </code>
                                                <!--**************** SOP Instance UID *****************-->
                                                <!-- Reference to SR Document -->
                                                <entryRelationship typeCode="COMP">
                                                    <observation classCode="DGIMG" moodCode="EVN">
                                                        <templateId root="2.16.840.1.113883.10.20.6.2.8"/>
                                                        <id
                                                        root="1.2.840.113619.2.62.994044785528.20060823.200608242334312.3"/>
                                                        <code code="1.2.840.10008.5.1.4.1.1.88.22"codeSystem="1.2.840.10008.2.6.1"
                                                            codeSystemName="DCMUID"displayName="Enhanced SR">
                                                        </code>
                                                        <text mediaType="application/dicom">
                                                            <reference value="http://www.example.org/wado?requestType=WADO
                                                                &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                                                                &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823222132232023
                                                                &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.9
                                                                &amp;contentType=application/dicom"/>
                                                            <!--reference to image 1 (PA) -->
                                                        </text>
                                                        <effectiveTime value="20060823223232"/>
                                                    </observation>
                                                </entryRelationship>
                                            </act>
                                        </entryRelationship>
                                        <!--**************** Series (CR Images) *****************-->
                                        <entryRelationship typeCode="COMP">
                                            <act classCode="ACT"
                                                moodCode="EVN">
                                                <id root="1.2.840.113619.2.62.994044785528.20060823223142485051"/>
                                                <code code="113015" codeSystem="1.2.840.10008.2.16.4"
                                                        codeSystemName="DCM" displayName="Series">
                                                    <qualifier>
                                                        <name code="121139" codeSystem="1.2.840.10008.2.16.4"
                                                            codeSystemName="DCM" displayName="Modality">
                                                        </name>
                                                        <value code="CR" codeSystem="1.2.840.10008.2.16.4"
                                                            codeSystemName="DCM" displayName="Computed Radiography">
                                                        </value>
                                                    </qualifier>
                                                </code>
                                                <!--**************** SOP Instance UID *****************-->
                                                <!-- 2 References (chest PA and LAT) -->
                                                <entryRelationship typeCode="COMP">
                                                    <observation classCode="DGIMG" moodCode="EVN">
                                                        <templateId root="2.16.840.1.113883.10.20.6.2.8"/>
                                                        <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/>
                                                        <code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1"
                                                            codeSystemName="DCMUID"displayName="Computed Radiography Image Storage">
                                                        </code>
                                                        <text mediaType="application/dicom">
                                                            <reference value="http://www.example.org/wado?requestType=WADO
                                                                &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                                                                &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                                                                &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                                                                &amp;contentType=application/dicom"/>
                                                            <!--reference to image 1 (PA) -->
                                                        </text>
                                                        <effectiveTime value="20060823223232"/>
                                                    </observation>
                                                </entryRelationship>
                                                <entryRelationship typeCode="COMP">
                                                    <observation classCode="DGIMG" moodCode="EVN">
                                                        <templateId root="2.16.840.1.113883.10.20.6.2.8"/>
                                                        <id root="1.2.840.113619.2.62.994044785528.20060823.200608232231422.3"/>
                                                        <code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1"
                                                            codeSystemName="DCMUID"displayName="Computed Radiography Image Storage">
                                                        </code>
                                                        <text
                                                            mediaType="application/dicom">
                                                            <reference value="http://www.example.org/wado?requestType=WADO
                                                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                                                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                                                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232231422.3
                                                            &amp;contentType=application/dicom"/>
                                                            <!--reference to image 2 (LAT) -->
                                                        </text>
                                                        <effectiveTime value="20060823223142"/>
                                                    </observation>
                                                </entryRelationship>
                                            </act>
                                        </entryRelationship>
                                    </act>
                                </entry>
                            </section>
                            <!--**************** End of DICOM Object Catalog Subsection *****************-->
                        </component>
                    </section>
                    <!--**************** End of Imaging Procedure Description Section *****************-->
                </component>
                <component>
                    <!--**************** Findings Section  *****************-->
                    <section>
                        <templateId root="2.16.840.1.113883.10.20.6.1.2"/>
                        <id root="1.2.840.10213.2.62.9940434234785528.114289545000804445"/>
                        <code code="59776-5" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Findings"/>
                        <title>Findings</title>
                        <text>
                            <paragraph>
                                <caption>Finding</caption>
                                <content ID="Fndng2">The cardiomediastinum is within normal limits. The trachea is midline.
                                The previously described opacity at the medial right lung base has cleared. There are no new
                                infiltrates. There is a new round density at the left hilus,superiorly (diameter about 45mm).
                                A CT scan is recommended for further evaluation. The pleural spaces are clear. The visualized
                                musculoskeletal structures and the upper abdomen are stable and unremarkable.</content>
                            </paragraph>
                            <paragraph>
                                <caption>Diameter</caption>
                                <content ID="Diam2">45mm</content>
                            </paragraph>
                            <paragraph>
                                <caption>Source of Measurement</caption>
                                <content ID="SrceOfMeas2">
                                    <linkHtml
                                        href="http://www.example.org/wado?requestType=WADO
                                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                                            &amp;contentType=application/dicom">Chest_PA</linkHtml>
                                </content>
                            </paragraph>
                        </text>
                        <entry>
                            <observation classCode="OBS" moodCode="EVN">
                                <!-- Text Observation -->
                                <templateId root="2.16.840.1.113883.10.20.6.2.12"/>
                                <code code="121071" codeSystem="1.2.840.10008.2.16.4"codeSystemName="DCM" displayName="Finding"/>
                                <value xsi:type="ED">
                                    <reference value="#Fndng2"/>
                                </value>
                                <!-- inferred from measurement -->
                                <entryRelationship typeCode="SPRT">
                                    <observation classCode="OBS" moodCode="EVN">
                                        <templateId root="2.16.840.1.113883.10.20.6.2.14"/>
                                        <code code="246120007" codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED"
                                            displayName="Nodule size">
                                            <originalText>
                                                <reference value="#Diam2"/>
                                            </originalText>
                                        </code>
                                        <!-- no DICOM attribute <statusCode code="completed"/> -->
                                        <effectiveTime value="20060823223912"/>
                                        <value xsi:type="PQ" value="45" unit="mm"/>
                                        <!-- inferred from image -->
                                        <entryRelationship typeCode="SUBJ">
                                            <observation classCode="DGIMG" moodCode="EVN">
                                                <templateId root="2.16.840.1.113883.10.20.6.2.8"/>
                                                <!-- (0008,1155) Referenced SOP Instance UID-->
                                                <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/>
                                                <!-- (0008,1150) Referenced SOP Class UID -->
                                                <code code="1.2.840.10008.5.1.4.1.1.1"codeSystem="1.2.840.10008.2.6.1"
                                                    codeSystemName="DCMUID"displayName="Computed Radiography Image Storage">
                                                </code>
                                                <text mediaType="application/dicom">
                                                    <!--reference to CR DICOM image (PA view) -->
                                                    <reference
                                                    value="http://www.example.org/wado?requestType=WADO
                                                        &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                                                        &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                                                        &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                                                        &amp;contentType=application/dicom"/>
                                                </text>
                                                <effectiveTime value="20060823223232"/>
                                                <!-- Purpose of Reference -->
                                                <entryRelationship typeCode="RSON">
                                                    <observation classCode="OBS" moodCode="EVN">
                                                        <templateId root="2.16.840.1.113883.10.20.6.2.9"/>
                                                        <code code="ASSERTION"codeSystem="2.16.840.1.113883.5.4"/>
                                                        <value xsi:type="CD" code="121112"codeSystem="1.2.840.10008.2.16.4"
                                                                codeSystemName="DCM"displayName="Source of Measurement">
                                                            <originalText>
                                                                <reference value="#SrceOfMeas2"
                                                                />
                                                            </originalText>
                                                        </value>
                                                    </observation>
                                                </entryRelationship>
                                            </observation>
                                        </entryRelationship>
                                    </observation>
                                </entryRelationship>
                            </observation>
                        </entry>
                    </section>
                    <!--**************** End of Findings Section *****************-->
                </component>
                <component>
                    <!--**************** Impressions Section *****************-->
                    <section>
                        <templateId root="1.2.840.10008.9.5"/>
                        <id root="1.2.840.10213.2.62.9940434234785528.114289545345927752"/>
                        <code code="19005-8" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Impressions"/>
                        <title>Impressions</title>
                        <text>
                            <paragraph>
                                <caption>Impression</caption>
                                <content ID="Fndng3">No acute cardiopulmonary process. Round density in left superior hilus, further
                                evaluation with CT is recommended as underlying malignancy is not excluded.</content>
                            </paragraph>
                        </text>
                        <entry>
                            <!-- Impression report element (TEXT) -->
                            <observation classCode="OBS" moodCode="EVN">
                                <!-- Text Observation -->
                                <templateId root="2.16.840.1.113883.10.20.6.2.12"/>
                                <code code="121073" codeSystem="1.2.840.10008.2.16.4"codeSystemName="DCM" displayName="Impression"/>
                                <value xsi:type="ED">
                                    <reference value="#Fndng3"/>
                                </value>
                            </observation>
                        </entry>
                    </section>
                    <!--**************** End of Impressions
                     Section *****************-->
                </component>
            </structuredBody>
        </component>
    </ClinicalDocument>

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