A.5.1.4.2 Procedure Context

CDA Header

Service Event Attribute Values default to DICOM SR „General Study“ Module Header Attribute Values.

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Figure A.5.1.3-6: CDA HEADER PROCEDURE CONTEXT (SERVICE EVENT)

Table A.5.1.3-11

SERVICE EVENT

Attribute Data Type Multiplicity Value
classCode CS 1..1 ACT
moodCode CS 1..1 EVN
id SET<II> 0..* Study Instance UID (0020,000D) of the General Study Module
code CE 0..1 Procedure Code Sequence (0008,1032) of the General Study Module or Procedure Code (Template 1005)
effectiveTime IVL<TS> 0..1 Set low value of interval using: Study Date (0008,0020) and Study Time (0008,0030) of the General Study Module

For the mapping of Physician(s) reading study to the performer participation refer to Service Event Performer Participation (Tables A.5.1.1-21 to A.5.1.1-23).

CDA Entries (Clinical Statement, Structured Body)

If individual sections are used to report on one or multiple procedures, the procedure code values of the Procedure Context (Template 1005) associated with the DICOM section container content item are mapped to the CDA clinical statement entry class attribute Act.code or Procedure.code. The selection of the “Procedure” or “Act” entry from the clinical statement choice box depends on the nature of the imaging service that has been performed. The “Procedure” entry shall be used for image-guided interventions and minimal invasive imaging services, whereas the “Act” entry shall be used for diagnostic imaging services (based on Procedure Code Sequence (0008,1032) or Procedure Code (Template 1005) values). The set of attributes is identical for the “Procedure” and “Act” Context.

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Figure A.5.1.3-7: PROCEDURE CONTEXT FOR IMAGE-GUIDED INTERVENTIONS

Figures A.5.1.3-7 and A.5.1.3-8 show the procedure context for image-guided interventions and diagnostic imaging services and its relationship to CDA document sections plus quantity measurements. The component act relationship between Section and Procedure/Act is encoded as a section entry in CDA; QuantityMeasurement as an observation CDA entry and the component act relationship between Procedure/Act and QuantityMeasurement as entryRelationship.

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Figure A.5.1.3-8: PROCEDURE CONTEXT FOR DIAGNOSTIC IMAGING SERVICES

Table A.5.1.3-12

COMMON SET OF ATTRIBUTES FOR PROCEDURE AND ACT CONTEXT

Attribute Data Type Multiplicity Value
classCode CS 1..1 ACT
moodCode CS 1..1 EVN
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.5” (identifies the template that defines constraints on “Procedure Context” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
id SET<II> 0..* Shall not be sent, refer to Study Instance UID (0020,000D) of General Study Module mapped to ServiceEvent.id that is applied via context conduction
code CE 1..1 Procedure Code (Section procedure context associated with DICOM section container content item:Template 1005)
text ED 0..1 Study Description (0008,1030) of the General Study Module
effectiveTime IVL<TS> 0..1 Set low value of interval using: Study Date (0008,0020) and Study Time (0008,0030) of the General Study Module