A.5.1.1 Header (Level 1)

General Remarks on the mapping of DICOM header module attributes:

SR Document General Module

— Custodian:The Type 3 DICOM Custodial Organization Sequence ((0040,A07C) attribute values of the original SR document are not necessarily the basis for mapping to the CDA Custodian Participation, related roles and entities, since the custodian values of the transformed CDA document shall be set according to institution policies.

— Mapping of the Participant Sequence (0040,A07A): Participations of type “SOURCE” (Equipment that contributed to the content) are not mapped to CDA Release 2. The DICOM Template 2000 (PS 3.16) does not specify default values for the device observer that are based on the participant sequence.

— Attributes of the Predecessor Documents Sequence (0040,A360) and Identical Documents Sequence (0040,A525) are not mapped since they are relevant only in the context of the original DICOM SR document.

— Attributes of the Current Requested Procedure Evidence Sequence (0040,A375), Pertinent Other Evidence Sequence (0040,A385) and Equivalent Document Sequence (0040,A090) are not mapped since they are relevant only in the context of the original DICOM SR document.

SOP Common Module

— Timezone Offset From UTC (0008,0201) shall be considered for attributes of the original DICOM SR document that are based on the DA or TM data type (PS 3.5).

— The Specific Character Set (0008,0005) is required (Type 1C), if the Basic Graphic Set is expanded or replaced. This is the basis for mapping DICOM character sets to CDA Unicode (<?xml version="1.0" encoding="UTF-8"?>)

Note: Ambiguities exist for mapping individual characters to unicode (e.g. for Japanese characters). Resolution of those issues is beyond the scope of this document. Please refer to Annex C for further details on data types and character sets.

Header Mapping Tables

[pic]

Figure A.5.1.1-1 : CLINICAL DOCUMENT HEADER PARTICIPATIONS

Clinical Document

Table A.5.1.1-1

CLINICAL DOCUMENT

Attribute Data Type Multiplicity Value
classCode CS 1..1 DOCCLIN
moodCode CS 1..1 EVN
id II 1..1 A UID with a maximum length of 64 bytes shall be assigned to the root portion of the HL7 V3 Instance Identifier (II) data type. There shall be no extension to the root portion of the Instance Identifier.
code CE 1..1 ”18748-4” as code property, 2.16.840.1.113883.6.1 as codeSystem property, LOINC as codeSystemName property, “Diagnostic Imaging Report” as displayName property.
title ST 1..1 Code Meaning (0008,0104) of ”Equivalent Meaning of Concept Name” (Template 1210) if code is available. If code is not present: Code Meaning (0008,0104) of Concept name code sequence (0040,A043) of the root content item. .
effectiveTime TS 1..1 Content Date (0008,0023), Content Time (0008,0033) of the SR Document General Module
confidentialityCode CE 1..1 Defaults to “N” (Normal confidentiality rules). Other values may be used in accordance with local policies.
languageCode CS 0..1 Code Sequence (0040,A043) of “Language of Content Item and Descendants” code content item (TID 1204): <code value as code property, coding scheme designator as codeSystemName property, code meaning as displayName property> (as defined by the IETF (Internet Engineering Task Force) RFC 3066)
setID II 0..1 Shall not be sent.
versionNumber INT 0..1 Shall not be sent.
copyTime TS 0..1 Deprecated, shall not be sent.

For the mapping of parent document attributes (i.e. the transformed original DICOM SR document) refer to Table A.5.1.1-19.

Authenticator Participation

The attributes of the SR Document General Module Participant Sequence (0040,A07A), PS 3.3 are mapped to the authenticator participation, associated role and entity as specied in Tables A.5.1.1-2 to A.5.1.1-4, if the participation type value equals “ATTEST” (Attestor). One or more such items of the Participant Sequence can be mapped to the authenticator participation which has cardinality 0..*.

Table A.5.1.1-2

AUTHENTICATOR PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 AUTHEN
time TS 1..1 Participation Datetime (0040,A082) of Participant Sequence (0040,A07A)
signatureCode CS 1..1 S (Signature has been affixed) if DICOM attestor attribute values are set in the original document.

Table A.5.1.1-3

ASSIGNED ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Person Identification Code Sequence (0040,1101) within Participant Sequence (0040,A07A): code value as identifier
code CE 0..1 Person Identification Code Sequence (0040,1101) within Participant Sequence (0040,A07A): <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.1-4

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Person Name (0040,A123) of Participant Sequence (0040,A07A)

Legal Authenticator Participation

The SR Document General Module attributes related to document verification (PS 3.3) are mapped to the legal authenticator participation, associated role and entities as specified in Tables A.5.1.1-5 to A.5.1.1-8.

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. The Verification Flag (0040,A493) cannot be mapped since CDA Release 2 does not specify such flags. If however legalAuthenticator attribute values are set, that implies that the document is verified. If not, the document is unverified. Recommendation: Each transformed DICOM SR document that is sent to information systems should be verified after it has been transcoded. Only verified documents should be exported.

Table A.5.1.1-5

LEGAL AUTHENTICATOR PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 LA
contextControlCode CS 1..1 OP
time TS 1..1 Verification DateTime (0040,A030) within Verifying Observer Sequence.
signatureCode CS 1..1 S (Signature has been affixed) if Verification Flag (0040,A493) Value equals “VERIFIED”.

Table A.5.1.1-6

ASSIGNED ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Verifying Observer Identification Code Sequence (0040,A088) : code value as identifier
code CE 0..1 Verifying Observer Identification Code Sequence (0040,A088) : <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.1-7

ORGANIZATION

Attribute Data Type Multiplicity Value
classCode CS 1..1 ORG
determinerCode CS 1..1 INSTANCE
id SET<II> 0..* Shall not be sent.
name SET<ON> 0..* Verifying Organization (0040,A027) within Verifying Observer Sequence
telecom SET<TEL> 0..* Shall not be sent.
addr SET<AD> 0..* Shall not be sent.
standardIndustryClassCode CE 0..1 Shall not be sent.

Table A.5.1.1-8

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Verifying Observer Name (0040,A075) within Verifying Observer Sequence

Information Recipient Participation

The referring physician is considered the primary information recipient for both, inpatient as well as outpatient delivery of imaging services by default.

Information on the attending physician may be encoded by using the encompassing encounter | encounter participation (refer to Tables A.5.1.1-25 to A.5.1.1-27). This participation may also be used for encoding information of the referrer if the primary information recipient is different from the referring physician.

The PRCP (Primary Information Recipient) code shall be used as a fixed value for type code as specified in Table A.5.1.1-9.

Table A.5.1.1-9

INFORMATION RECIPIENT PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 PRCP

Attribute values of the original SR document General Study Module, Referring Physician Identification Sequence (0008,0096) are mapped as specified in Tables A.5.1.1-10 to A.5.1.1-12. Only a single item is permitted in this sequence.

Table A.5.1.1-10

ASSIGNED ENTITY ROLE

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 0..* Person Identification Code Sequence (0040,1101) of Referring Physician Identification Sequence (0008,0096): code value as identifier
addr SET<AD> 0..* Person’s Address (0040,1102) of Referring Physician Identification Sequence (0008,0096): DICOM ST (Short Text) String Data Type
telecom SET<TEL> 0..* Person’s Telephone Numbers (0040,1103) of Referring Physician Identification Sequence (0008,0096): DICOM LO (Long String) String Data Type

Table A.5.1.1-11

ORGANIZATION

Attribute Data Type Multiplicity Value
classCode CS 1..1 ORG
determinerCode CS 1..1 INSTANCE
id SET<II> 0..* Institution Code Sequence (0008,0082) of Referring Physician Identification Sequence (0008,0096): code value as identifier (will not be used if Institution Name is present)
name SET<ON> 0..* Institution Name (0008,0080) of Referring Physician Identification Sequence (0008,0096) (will not be used if Institution Code Sequence is present and code value is mapped to id).
telecom SET<TEL> 0..* Shall not be sent.
addr SET<AD> 0..* Institution Address (0008,0081) of Referring Physician Identification Sequence (0008,0096)
standardIndustryClassCode CE 0..1 Shall not be sent.

Table A.5.1.1-12

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Referring Physician's Name (0008,0090)

Data Enterer Participation

The attributes of the SR Document General Module Participant Sequence (0040,A07A), PS 3.3 are mapped to the dataEnterer participation, associated role and entity as specied in Tables A.5.1.1-13 to A.5.1.1-15 if the participation type value equals “ENT” (Data Enterer). 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 (dataEnterer participation has cardinality 0..1).

Table A.5.1.1-13

DATA ENTERER PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 ENT
contextControlCode CS 1..1 OP
time TS 0..1 Participation Datetime (0040,A082) of Participant Sequence (0040,A07A) if Participation Type (0040,A080) equals “ENT” (Data Enterer).

Table A.5.1.1-14

ASSIGNED ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Person Identification Code Sequence (0040,1101) within Participant Sequence (0040,A07A): code value as identifier
code CE 0..1 Person Identification Code Sequence (0040,1101) within Participant Sequence (0040,A07A): <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.1-15

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Person Name (0040,A123) of Participant Sequence (0040,A07A) if Participation Type (0040,A080) equals “ENT” (Data Enterer).

participant (Referrer) Participation

Attribute values of the original SR document General Study Module, Referring Physician Identification Sequence (0008,0096) are mapped as specified in Tables A.5.1.1-16 to A.5.1.1-18. Only a single item is permitted in this sequence.

Table A.5.1.1-16

REFERRING PHYSICIAN ENCOUNTER PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 REF
time IVL<TS> 0..1 Shall not be sent.

Table A.5.1.1-17

Assigned Entity

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Referring Physician Identification Sequence (0008,0096): code value as identifier
code CE 0..1 Referring Physician Identification Sequence (0008,0096): <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Person’s Address (0040,1102) of Referring Physician Identification Sequence (008,0096): DICOM ST (Short Text) String Data Type
telecom SET<TEL> 0..* Person’s Telephone Numbers (0040,1103) of Referring Physician Identification Sequence (008,0096): DICOM LO (Long String) String Data Type

Table A.5.1.1-18

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Referring Physician's Name (0008,0090)

[pic]

Figure A.5.1.1-2: CLINICAL DOCUMENT HEADER ACT RELATIONSHIPS

Parent Document

RelatedDocument act relationship: Set typeCode to fixed value “XFRM” (for transformed parent DICOM SR document). The multiplicity of the act relationship is constrained to cardinality 1..1 (for a single original DICOM SR document that has been transformed to CDA).

Related Parent Document

The SOP Instance UID (0008,0016) attribute value of the SOP Common Module is mapped to the required CDA attribute ParentDocument.id.

Table A.5.1.1-19

PARENT DOCUMENT

Attribute Data Type Multiplicity Value
classCode CS 1..1 DOCCLIN
moodCode CS 1..1 EVN
id SET<II> 1..* SOP Instance UID of original DICOM SR Composite Object.
code CD 1..1 DICOM SR Report Title: Concept Name Code Sequence (0040,A043) of Root Content Item.
text ED 0..1 Shall not be sent.
setID II 0..1 Shall not be sent.
versionNumber INT 0..1 Shall not be sent.

Order Fulfillment

If available from the source SR document, at least one of the following numbers of DICOM Template 1005 “Procedure Context” should be mapped to the CDA Order.id set of instance identifiers: Placer Number, Filler Number or Accession Number. Each of the numbers should be combined with “Issuer of Identifier” (TID 1005) if available. Multiple procedure codes and the associated placer/filler/accession number(s) can be mapped to order acts as specified in Table A.5.1.1-20 (the CDA act relationship “infulfillmentOf” has cardinality 0..*).

Table A.5.1.1-20

ORDER

Attribute Data Type Multiplicity Value
classCode CS 1..1 ACT
moodCode CS 1..1 RQO
id SET<II> 1..* Placer Number (TID 1005) and/or Filler Number (TID 1005) and/or Accession Number (TID 1005), each of them combined with its associated Issuer of Identifier (TID 1005) if available. Accession Number (TID 1005) defaults to Accession Number (0008,0050) of the General Study Module.
code CE 0..1 Requested Procedure Code Sequence (0032,1064) within the Referenced Request Sequence (0040,A370) of the SR Document General Module
priorityCode CE 0..1 Shall not be sent.

Service Event

For the diagram related to the serviceEvent mapping refer to section A.5.1.4.2 Procedure Context.

DICOM General Study Attributes Mapping:

— Physician(s) Reading Study attributes are mapped to the service event act class performer participation, associated roles and entities (refer to Tables A.5.1.1-21 to A.5.1.1-23).

— Physician(s) of Record attributes are mapped to the encompassing encounter act | encounter participation (typeCode = “ATND” for Attender), associated roles and entities (refer to Tables A.5.1.1-25 to A.5.1.1-27 and the information recipient section for the relationship to the primary information recipient).

Service Event Performer Participation

Attribute values of original SR document General Study Module, Physician(s) Reading Study (0008,1060) and Physician(s) Reading Study Identification Sequence (0008,1062) are mapped as specified in Tables A.5.1.1-21 to A.5.1.1-23. Information on multiple physicians can be mapped to multiple AssignedEntity roles and and Person entities since the encounterParticipant participation has cardinality 0..*.

Table A.5.1.1-21

PHYSICIAN(S) READING STUDY PERFORMER PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 PRF
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.1” (identifies the template that defines constraints on “Physician Reading Study Performer” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
functionCode CE 0..1 Shall not be sent.
time IVL<TS> 0..1 Shall not be sent.

Table A.5.1.1-22

ASSIGNED ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Person Identification Code Sequence (0040,1101) within Physician(s) Reading Study Identification Sequence (0008,1062): code value as identifier
code CE 0..1 Person Identification Code Sequence (0040,1101) within Physician(s) Reading Study Identification Sequence (0008,1062): <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.1-23

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Name of Physician(s) Reading Study (0008,1060)

Encompassing Encounter

EncompassingEncounter shall be sent if there is information on either the admission or the attender participation and not otherwise. EncompassingEncounter.effectiveTime is a required attribute. There is no DICOM SR attribute specified that can be mapped, i.e. Visit Date and Time are not available. If the value cannot be obtained from some other source, the null flavor “NI” (No Information) is assigned as the default Encompassing Encounter effectiveTime value. A complete list of null flavor values is available in CDA R2 DIR IG.

Table A.5.1.1-24

ENCOMPASSING ENCOUNTER

Attribute Data Type Multiplicity Value
classCode CS 1..1 ENC
moodCode CS 1..1 EVN
id SET<II> 0..* Admission Id (0038,0010) and Issuer of Admission ID Sequence (0038;0014) of the Patient Study Module
code CE 0..1 Shall not be sent
effectiveTime IVL<TS> 1..1 Use null flavor value “NI” (No Information) if the value cannot be obtained from some other source.
dischargeDispositionCode CE 0..1 Shall not be sent

Attender Participation

Attribute values of Physician(s) of Record (0008,1048) and the Physician(s) of Record Identification Sequence (0008,1049) within the General Study module (PS 3.3) are mapped to the encompassing encounter act | encounter participation (typeCode = “ATND” for Attender), associated roles and entities. Information on multiple physicians can be mapped to multiple AssignedEntity roles and and Person entities since the encounterParticipant participation has cardinality 0..*.

Table A.5.1.1-25

PHYSICIAN(S) OF RECORD ATTENDER PARTICIPATION

Attribute Data Type Multiplicity Value
typeCode CS 1..1 ATND
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.2” (identifies the template that defines constraints on “Physician of Record Participant” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
time IVL<TS> 0..1 Shall not be sent.

Table A.5.1.1-26

ASSIGNED ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
id SET<II> 1..* Person Identification Code Sequence (0040,1101) within Physician(s) of Record Identification Sequence (0008,1049): code value as identifier
code CE 0..1 Person Identification Code Sequence (0040,1101) within Physician(s) of Record Identification Sequence (0008,1049): <code value as code property, coding scheme UID as codeSystem property, coding scheme designator as codeSystemName property, code meaning as displayName property>
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.1-27

PERSON

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Physician(s) of Record (0008,1048)