A.3.2 Document Body

A.3.2.1 DICOM SR “Basic Diagnostic Imaging Report” Template Structure

Template 2000 is the top-level template of DICOM SR Basic Diagnostic Imaging Reports (PS 3.16). It includes sub-templates as shown in Figure A.3.2.1-1. The root content item (coded report title) and the Content Sequence details (structure and contents) are specified by those templates.

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Figure A.3.2.1-1: TEMPLATE STRUCTURE SUMMARIZED FROM PS 3.16

A.3.2.2 Mapping Requirements

The goal of this document is to specify a mapping between constrained TID 2000 Basic Diagnostic Imaging Report DICOM SR documents (PS 3.16) and HL7 CDA Diagnostic Imaging Reports (HL7 CDA R2 DIR IG, R1-2009). The following constraints apply to DICOM SR Basic Diagnostic Imaging Reports that are mapped to CDA Diagnostic Imaging Reports:

— Subject Context, Patient (TID 1007): The constrained DICOM SR Basic Diagnostic Imaging Report is restricted to cover exactly one patient subject.

— Subject Context, Specimen (TID 1009): The mapping of “Subject Context, Specimen” (Template 1009) is out of scope for this version of the implementation guide.

— “Subject Context, Device” (TID 1010) and reports on animals are not addressed by this implementation guide.

— The mapping of DICOM SR clinical trial header data (Clinical Trial Subject Module, Clinical Trial Study Module, Clinical Trial Series Module) is out of scope for this version of the implementation guide.

— The transformation of de-identified SR documents (e.g. for clinical trials and educational purposes) is not addressed in this version of the implementation guide. CDA Release 2 does not address de-identification explicitly (e.g. by definition of flags). De-identified SR documents that have been transformed in accordance with this guide will not be able to have original patient information recovered.

— The transformation of DICOM Patient Study Module attributes in the document header is out of scope. Pertinent clinical information may be present in the SR content tree and will be mapped to the CDA document body.

— The transcoding of encrypted DICOM SR documents to CDA Release 2 is not addressed in this version of the implementation guide.

— Since the use of digital signatures for transcoded DICOM SR documents is not primarily a mapping question, this topic is not addressed in the implementation guide.

— SR Document General Module, Verifying Observer Sequence (0040,A073): The constrained DICOM SR Basic Diagnostic Imaging Report is restricted to cover exactly one Verifying Observer since CDA R2 only allows for a single Legal Authenticator.

— SR Document General Module, Participant Sequence (0040,A07A): The constrained DICOM SR Basic Diagnostic Imaging Report is restricted to cover exactly one Data Enterer since CDA R2 only allows for a single dataEnterer.

— For automated transformation of DICOM SR diagnostic imaging report it is recommended to transform only SR documents where the DICOM Completion Flag (0040,A491) value equals “COMPLETE” to make sure that only SR documents get exported that contain all significant observations (the completeness of the content will be attested or verified by an authorized user). The value of the completion flag can be ignored, if an authorized user confirms that the SR document contains all significant observations. The Completion Flag (0040,A491) cannot be mapped since CDA Release 2 does not specify such flags.

— Spatial coordinates contained in the content tree of the original DICOM SR document are not mapped because this guideline assumes that Presentation States are used to convey such information.

The CDA Diagnostic Imaging Report Implementation Guide (HL7 CDA R2 DIR IG, R1-2009) defines constraints on CDA Header and Body elements used in a Diagnostic Imaging Report document. Performing the mapping and setting CDA specific values as specified in this transformation guide and adhering to the constraints of CDA Diagnostic Imaging Reports (DIR) results in CDA DIR conformant reports. Validation of the generated CDA DIR documents is based on the constraints specified for CDA Diagnostic Imaging Reports (HL7 CDA R2 DIR IG, R1-2009).

A.3.2.3 DICOM Composite Object References Context Requirements

The attributes of DICOM composite object references are specified in Annex B: HL7 V3 DICOM CMETs (Common Message Element Types). These CDA mapping patterns shall be used to reference DICOM composite objects. Information on relevant DICOM objects referenced within the CDA target document’s body and on the original DICOM SR document shall be included in the CDA DICOM object catalog section.