A.5.1.2 Section (Level 2)

General Mapping of Document Sections

DICOM SR Section Container Content Items are mapped to CDA Clinical Document Sections. CDA section elements shall have a code element which shall contain a LOINC code if available, or DICOM codes for sections which have no LOINC equivalent. The mapping of section codes is specified in CDA R2 DIR IG.

Table A.5.1.2-1 

CDA SECTION

Attribute Data Type Multiplicity Value
classCode CS 1..1 DOCSECT
moodCode CS 1..1 EVN
templateId LIST<II> 1..* Set root portion of II to: - “2.16.840.1.113883.10.20.6.1.1” for DICOM Object Catalog sections - “2.16.840.1.113883.10.20.6.1.2” for Findings sections (values identify the templates that define constraints on section content of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
id II 0..1 Generate Section Identifier
code CE 1..1 If no equivalent LOINC section code is available, DICOM section codes contained in Concept Name Code Sequence (0040,A043) of the DICOM SR Container Content Item are used: <code value as code property, "1.2.840.10008.2.16.4" as codeSystem property, "DCM" as codeSystemName property, code meaning as displayName property>. If an equivalent LOINC section code is available, DICOM section codes are mapped to LOINC as specified by CDA R2 DIR IG: <mapped code value as code property, "2.16.840.1.113883.6.1" as codeSystem property, "LOINC" as codeSystemName property, mapped code meaning as displayName property>
title ST 0..1 If section title is intended to be rendered: Code meaning of Concept Name Code Sequence (0040,A043) of the DICOM SR Container Content Item.
text ED 0..1 If section text is intended to be rendered: Narrative text
confidentialityCode CE 0..1 If used the value defaults to “N” (Normal confidentiality rules). Other values may be used in accordance with local policies.
languageCode CS 0..1 Shall not be sent.

CDA Section Text

Section.text contains the narrative text (attested content) of the document. Section.text is populated from DICOM SR content items of the original document in a way that the full meaning can be conveyed in an unambiguous manner by applications that render the document.

Structured CDA entries may be referenced within the narrative section text of the CDA document (refer to the CDA Release 2 Standard, Section 4.3.5.1 on <content>). Parts of the structured body of the CDA document that are part of the attested content of the document shall be included in the narrative section text. To that end corresponding CDA entries are extended by originalText elements and reference values that can be derived from the entry act class code displayName.

<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>

CDA Sample Document Excerpt 1: CODE OBSERVATION REFERENCE

<observation classCode="OBS" moodCode="EVN">

<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>

CDA Sample Document Excerpt 2: TEXT OBSERVATION REFERENCE

Within section text a new paragraph may be used for CDA entries that are inserted as part of the attested content. The caption value may be derived from the code displayName value. The attribute value of the reference value shall be used for the content ID attribute.

<paragraph>

<caption>Source of Measurement</caption>

<content ID=" SrceOfMeas2"/>

</paragraph>

<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>

CDA Sample Document Excerpt 3: SECTION TEXT PARAGRAPH

For CDA entries (structured part) WADO references are included in observation text as reference value.

<observation classCode="DGIMG" moodCode="EVN">

<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>

</observation>

CDA Sample Document Excerpt 4: OBSERVATION TEXT WADO REFERENCE

Within section text the same WADO reference may be included as the linkHtml href attribue value and the element value can be derived from the DICOM Study Description attribute value.

<linkHtml href="http://www.example.org/wado?requestType=WADO&amp;studyUID=1.2.840.113619.2.62.994044785528.1142

89542805&amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051&amp;objectUID=1.2.840.1

13619.2.62.994044785528.20060823.200608232232322.3&amp;contentType=application/DICOM">Chest_PA

</linkHtml>

CDA Sample Document Excerpt 5: SECTION TEXT WADO REFERENCE

Section.title and Section.text values shall be populated as shown in Table A.5.1.2-1 above if the section is intended to be rendered. Sections that are not intended to be rendered such as the DICOM Objects Catalog shall not contain title and/or text values.

Structured Body and Sections

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Figure A.5.1.2-1: NESTED SECTIONS

DICOM SR Basic Diagnostic Imaging Reports include nested container content items. The root content item (value type “CONTAINER” ) includes document sections (content items of value type “CONTAINER”) by applying relationships between those content items (relationship type “CONTAINS”).

The ClinicalDocument act class is associated with the StructuredBody act class by an act relationship (typeCode “COMP”). The structured body of the CDA contains sections that may be nested (recursive act relationship, typeCode = “COMP”). Nested DICOM SR sections within the document body are not used for SR Basic Diagnostic Imaging Reports (Template 2000). For other SR document types nested sections are mapped as shown in Figure A.5.1.2-1 (recursive component act relationship).

DICOM Object Catalog Section

The DICOM Object Catalog Section provides a single location for the identifying information of the study/series/instance hierarchical context of DICOM composite objects that are referenced for a specific purpose (Refer to Section A.7: Dicom Section (COCT_RM830110UV) for details. In the context of the CDA, entry act class and actRelationships names shall be used as specified for the CDA mapping).