A.5.1.4 DICOM SR Observation Context

The observation context comprises the observer context data (the human observer or device that made the observation), the procedure context data (related to data acquisition and interpretation) and the subject context data (for patient, specimen and fetus being subject to the reported procedure). Sections A.5.1.4.1, A.5.1.4.2 and A.5.1.4.3 specify the mapping.

A.5.1.4.1 Subject Context

Subject Context, Patient

[pic]

Figure A.5.1.3-4: PATIENT CONTEXT

DICOM template 2000 (PS 3.16) constrains the multiplicity of the patient subject to one per document. Attributes of the Patient Module (PS 3.3) and the Patient Subject Context (Template 1007, PS 3.16) are mapped to the recordTarget participation, associated roles and entities, if the Subject Class Code (Template 1006, PS 3.16) equals "Patient”.

Table A.5.1.3-7

PATIENT ROLE

Attribute Data Type Multiplicity Value
classCode CS 1..1 PAT
id SET<II> 1..* “Subject ID”: Defaults to value of Patient ID(0010,0020) in Patient Module. Other Patient IDs (0010,1000): may be mapped if appropriate infrastructure (master person index) and policies for domain identifier assignment are in place. The SET <II> data type does not provide use codes to distinguish multiple patient identifiers.
addr SET<AD> 0..* Patient’s Address (0010,1040) in Patient Demographic Module.
telecom SET<TEL> 0..* Patient’s Telephone Numbers (0010,2154) ) in Patient Demographic Module.

Note: If information on Issuer of Patient ID is available from the DICOM SR document (Patient Module), Universal Entity ID (0040,0032) of the Issuer of Patient ID Qualifiers Sequence (0010,0024) are mapped to PatientRole.id II root and Patient ID (0010,0020) to PatientRole.id II extension. Otherwise a globally unique identifier (ISO Object Identifier) may be generated for the PatientRole.id II root portion. If available Issuer of Patient ID (0010,0021) shall be mapped to PatientRole.id assigningAuthorityName.

Table A.5.1.3-8

PATIENT ENTITY

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* "Subject Name”: Defaults to value of Patient’s Name (0010,0010) in Patient Module. Other Patient Names (0010,1001) may be mapped , appropriate infrastructure (master person index) and policies for domain identifier assignment are in place. No specific use codes are provided by DICOM.
administrativeGenderCode CE 0..1 "Subject Sex”: Defaults to value equivalent to Patient’s Sex (0010,0040) in Patient Module. The DICOM coded string (CS) values maps to HL7 V3 administrativeGenderCode values (codeSystem="2.16.840.1.113883.5.1") as follows:
DICOM HL7 V3
CS Meaning Concept Code Print Name
F Female F Female
M Male M Male
O Undetermined sex Use “UNK” (unknown) null flavour value
“Subject Sex” value not available Use appropriate null flavour value
birthTime TS 0..1 "Subject Birth Date”: Defaults to value of Patient’s Birth Date (0010,0030) in Patient Module.
maritalStatusCode CE 0..1 Shall not be sent.
religiousAffiliationCode CE 0..1 Shall not be sent.
raceCode CE 0..1 Shall not be sent.
ethnicGroupCode CE 0..1 Ethnic Group (0010,2160) of Patient Module if present. (DICOM short string: SH shall be converted to the appropriate ethnicGroupCode attribute code)

Subject Context, Fetus

Document Level

The header attributes shall contain values for mother as specified in Table A.5.1.3-7 and A.5.1.3-8. Refer to figure A.5.1.3-4 for an overview on the recordTarget participation. The mother of the fetus is considered the patient and is therefore the recordTarget. Patient.name (Patient Entity, Table A.5.1.3-8) or "Subject Name”: Defaults to value of Patient’s Name (0010,0010) in Patient Module, which shall be identical to TID 1008 PNAME (“Mother of fetus”).

Section Level

The fetus subject is specified at section level.

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Figure A.5.1.3-5: SUBJECT CONTEXT, FETUS

Table A.5.1.3-9

RELATED SUBJECT, FETUS

Attribute Data Type Multiplicity Value
classCode CS 1..1 PRS (Personal Relationship)
code CE 1..1 “Fetus” code (CID 271) extends value domain PersonalRelationshipRoleType <121026> as code property, 1.2.840.10008.2.16.4 as codeSystem property, DCM as codeSystemName property, “Fetus” as displayName property>
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.3” (identifies the template that defines constraints on “Fetus Subject Context” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
administrativeGenderCode CE 0..1 Shall not be sent.
birthTime TS 0..0 Shall not be sent.

Table A.5.1.3-10

SUBJECT PERSON, FETUS

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 1..1 Subject ID or Fetus ID (TID 1008)
telecom SET<TEL> 0..* Shall not be sent.

CDA Release 2 does not specify a subject ID for mapping of Fetus Subject UID. Also the DICOM SR NUM content item that conveys the number of fetuses cannot be mapped because CDA Release 2 does not specify such an attribute. The fetus subject is always mapped in combination with the mother record target artifacts.

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

A.5.1.4.3 Observer Context

The Observer Context (TID 1002, PS 3.16) maps to the author participation and associated roles and entities at document or section level. DICOM specifies a Person Observer (TID 1003, PS 3.16) and a Device Observer (TID 1004, PS 3.16). Depending on the DICOM SR Observer Type, attribute values are mapped to the Person or AuthoringDevice Entity in the AuthorChoice Box.

The Person and Device Observer Context used at document level (Figure A.5.1.3-9) may be overridden at section level (Figure A.5.1.3-10).

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Figure A.5.1.3-9: DOCUMENT OBSERVER CONTEXT

[pic]

Figure A.5.1.3-10: SECTION OBSERVER CONTEXT

Table A.5.1.3-13

AUTHOR PARTICIPATION (FOR BOTH PERSON AND DEVICE OBSERVER)

Attribute Data Type Multiplicity Value
typeCode CS 1..1 AUT
functionCode CE 0..1 Shall not be sent
contextControlCode CS 1..1 “OP”
time TS 1..1 Content Date (0008,0023), Content Time (0008,0033) of the SR Document General Module and Timezone Offset from UTC (0008,0201) from SOP Common Module

A.5.1.4.3.1 Person Observer

Attribute values of Template 1003 in PS 3.16 “Person Observer Identifying Attributes” and the SR Document General Module are mapped to the CDA author participation, associated role and entities as specified in tables A.5.1.3-13 and A.5.1.3-14 to A.5.1.3-16. The DICOM attribute values of Person Observer’s Role in this procedure and Person Observer’s Role in the Organization cannot be mapped to CDA Release 2 since it does not specify equivalent attributes.

Table A.5.1.3-14

ASSIGNED AUTHOR, PERSON OBSERVER CONTEXT

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
templateId LIST<II> 1..* At section level set root portion of II to “2.16.840.1.113883.10.20.6.2.4” (identifies the template that defines constraints on “Observer Context” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
id SET<II> 1..* Person Identification Code Sequence (0040,1101) of Author Observer Sequence (0040,A078) in SR Document General Module.
addr SET<AD> 0..* Shall not be sent.
telecom SET<TEL> 0..* Shall not be sent.

Table A.5.1.3-15

ORGANIZATION, PERSON OBSERVER CONTEXT

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 Author Observer Sequence (0040,A078) in SR Document General Module
name SET<ON> 0..* Defaults to Institution Name (0008,0080) of the General Equipment Module; otherwise Person Observer’s Organization Name as specified in TID 1003 is used.
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.5.1.3-16

PERSON, PERSON OBSERVER CONTEXT

Attribute Data Type Multiplicity Value
classCode CS 1..1 PSN
determinerCode CS 1..1 INSTANCE
name SET<PN> 0..* Defaults to Person Name (0040,A123) of Author Observer Sequence (0040,A078) in SR Document General Module; otherwise Person Observer Name as specified in TID 1003 is used.

A.5.1.4.3.2 Device Observer

Attribute values of Template 1004 in PS 3.16 “Device Observer Identifying Attributes” and the SR Document General Module are mapped to the CDA author participation, associated role and entities as specified in tables A.5.1.3-13 and A.5.1.3-17 to A.5.1.3-19. DICOM does not specify attributes that could be mapped to MaintainedEntity role and associated Person entity.

Table A.5.1.3-17

ASSIGNED AUTHOR, DEVICE OBSERVER CONTEXT

Attribute Data Type Multiplicity Value
classCode CS 1..1 ASSIGNED
templateId LIST<II> 1..* At section level set root portion of II to “2.16.840.1.113883.10.20.6.2.4” (identifies the template that defines constraints on “Observer Context” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
id SET<II> 1..* Device Observer UID as specified in TID 1004
addr SET<AD> 0..* Device Observer Physical Location During Observation as specified by TID 1004 is used.
telecom SET<TEL> 0..* Shall not be sent.

The DICOM attribute Device Observer Serial Number specified in TID 1004 cannot be mapped to CDA Release 2 because there is no equivalent attribute specified.

Table A.5.1.3-18

AUTHORING DEVICE, DEVICE OBSERVER CONTEXT

Attribute Data Type Multiplicity Value
classCode CS 1..1 DEV
determinerCode CS 1..1 INSTANCE
code CE 0..1 Defaults to Station Name (0008,1010) of Author Observer Sequence (0040,A078) in SR Document General Module.
manufacturerModelName SC 0..1 Defaults to Manufacturer’s Model Name (0008,1090) of Author Observer Sequence (0040,A078) in SR Document General Module; otherwise to Device Observer Model Name as specified by TID 1004 is used.
softwareName SC 0..1 Shall not be sent.

Table A.5.1.3-19

ORGANIZATION, DEVICE OBSERVER CONTEXT

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..* Manufacturer (0008,0070) of Author Observer Sequence (0040,A078) in SR Document General Module
telecom SET<TEL> 0..* Shall not be sent.
addr SET<AD> 0..* Shall not be sent.
standardIndustryClassCode CE 0..1 Shall not be sent.