A.5 HL7 CDA Release2 Diagnostic Imaging Report Target Structure

The HL7 development framework (HDF) uses a model driven methodology and the derivation of specifications and interim work products from a common set of reference models (HL7 V3 Guide). The basis for Refined Message Information Models is the HL7 Reference Information Model (RIM). The CDA RMIM contains act classes, entities, roles and participations derived from the core RIM artifacts. The structured part of the CDA RMIM (Clinical Statement) specifies generic act entry classes such as act and observation. The code attribute of the entry classes is used to convey the semantic information while generic class names are used for the different act entries. Similarly the type code of the entry relationships denotes the semantics of the relationship between act entries.

The HL7 CDA XML representation builds on the HL7 V3 XML Implementation Technology Specification – Data Types and XML Implementable Technology Specification for V3 Structures. XML structures are derived from Hierarchical Message Descriptions (HMD).

The header of the transcoded diagnostic imaging report contains the participations and act relationships that are related to the central ClinicalDocument act class. The clinical document contains the structured body of the CDA document that consists of one or multiple sections. Each document section contains an optional section code and narrative text. Sections are associated with optional entry act classes and their related participations. Entry act classes are connected by act relationships that denote the type of relationship between individual act entries.

DICOM UIDs are mapped to HL7 V3 Instance Identifier (II) data type root. Non UID DICOM identifiers and numbers are mapped to the HL7 V3 Instance Identifier (II) data type extension portion. In this case the root value of the assigning authority (custodian organization) shall be used.

A.5.1 Constrained HL7 CDA Release 2 Diagnostic Imaging Report RMIM

The constrained CDA RMIM for Diagnostic Imaging Reports transcoded from DICOM SR Basic Diagnostic Imaging Reports shows the relevant artifacts of the target CDA document (refer to CDA Diagnostic Imaging Report RMIM).

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)

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

[pic]

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).

A.5.1.3 Structured Body (Level 3)

Coded Observations

DICOM Template 2000 specifies that Imaging Report Elements of Value Type Code are contained in sections (row 6 and 8). The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations (Row 9) that consist of image references and measurements (linear, area, volume and numeric). Coded DICOM Imaging Report Elements in this context are mapped to CDA coded observations that are section components and are related to the SopInstance or QuantityMeasurement act classes by the SPRT (Support) act relationship (Figure A.5.1.3-1).

[pic]

Figure A.5.1.3-1: CODED OBSERVATION WITHIN SECTION

Table A.5.1.3-1 shows the mapping of attribute values for DICOM Imaging Report Elements to CDA coded observation. The component act relationship between Section and CodedObservation is encoded as a section entry in CDA; CodedObservation as an observation CDA entry and the support act relationship as entryRelationship.

Table A.5.1.3-1

CODED OBSERVATION (DICOM IMAGING REPORT ELEMENT, VALUE TYPE CODE)

Attribute Data Type Multiplicity Value
classCode CS 1..1 OBS
moodCode CS 1..1 EVN
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.13” (identifies the template that defines constraints on “Code Observation” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
code CE 1..1 Concept Name Code Sequence (0040,A043) of CODE Content Item: ): <code value as code property, coding scheme designator as codeSystemName property, code meaning as displayName property>
effectiveTime TS 0..1 Observation DateTime (0040,A032)
languageCode CE 0..1 Not used at entry level.
value CE 1..1 Concept Code Sequence (0040,A168) of CODE Content Item: <code value as code property, coding scheme designator as codeSystemName property, code meaning as displayName property>

Text Observations

DICOM Template 2000 specifies that Imaging Report Elements of Value Type Text are contained in sections (Rows 6 and 10). The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations (Row 11) that consist of image references and measurements (linear, area, volume and numeric). Coded DICOM Imaging Report Elements in this context are mapped to CDA text observations that are section components and are related to the SopInstance or QuantityMeasurement act classes by the SPRT (Support) act relationship (Figure A.5.1.3-2).

[pic]

Figure A.5.1.3-2: TEXT OBSERVATION WITHIN SECTION

Table A.5.1.3-2 shows the mapping of attribute values for DICOM Imaging Report Elements to CDA text observation. The component act relationship between Section and TextObservation is encoded as a section entry in CDA; TextObservation as an observation CDA entry and the support act relationship as entryRelationship.

Table A.5.1.3-2

TEXT OBSERVATION

Attribute Data Type Multiplicity Value
classCode CS 1..1 OBS
moodCode CS 1..1 EVN
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.12” (identifies the template that defines constraints on “Text Observation” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
code CE 1..1 Concept Name Code Sequence (0040,A043) of TEXT Content Item: ): <code value as code property, coding scheme designator as codeSystemName property, code meaning as displayName property>
effectiveTime TS 0..1 Observation DateTime (0040,A032)
languageCode CE 0..1 Not used at entry level.
value ED 1..1 Text Value (0040,A160) of TEXT Content Item

Image References and Measurements within Section

Image references and measurements (linear, area, volume and numeric) may also be inserted directly within sections (Template 2000, Rows 6 and 12). In this case CDA sections are related to SopInstance and/or QuantityMeasurement act classes via component (COMP) act relationships.

Quantity Measurement + DICOM Composite Object References

For the modeling of DICOM Composite Object References refer to section A.7: Updated pattern based on A_DicomCompositeObjectReference minimal (COCT_RM830120UV). In the context of the CDA, entry act class and actRelationships names shall be used as specified for the CDA mapping.

The mapping of observations (i.e. quantity measurements based on image data) is specified below (structured contents of linear, area, volume and numeric measurements). The updated pattern based on CMET COCT_RM830120 „ReferencedDicomComposite Object“ (refer to section A.7) is reused for the mapping. Instead of starting directly with the SopInstance Act Class, the COCT_RM830120 pattern is applied in the context of Quantity Measurements (refer to Figure A.5.1.3-3 for details).

Quantity Measurement Act Class (Observation)

Table A.5.1.3-3

QUANTITY MEASUREMENT

Attribute Data Type Multiplicity Value
classCode CS 1..1 OBS
moodCode CS 1..1 EVN
templateId LIST<II> 1..* Set root portion of II to “2.16.840.1.113883.10.20.6.2.14” (identifies the template that defines constraints on “Quantity Measurement Observation” of CDA Diagnostic Imaging Reports as specified by CDA R2 DIR IG).
code CE 1..1 If a DICOM code is used in Concept Name Code Sequence (0040,A043) of Numeric Measurement (NUM) Content Item: <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 a SNOMED code is used in Concept Name Code Sequence (0040,A043) of Numeric Measurement (NUM) Content Item: <mapped code value as code property, "2.16.840.1.113883.6.96" as codeSystem property, "SRT" as codeSystemName property, mapped code meaning as displayName property>. Please refer to table 33 for the mapping of linear measurement codes, table 34 for the mapping of area measurement codes and table 35 for the mapping of volume measurement codes.
effectiveTime TS 0..1 Observation DateTime (0040,A032)
languageCode CE 0..1 Not used at entry level.
value PQ 1..1 The Numeric Value (0040,A30A) DICOM decimal string (DS data type) is mapped to the value component of the PQ data type (real number). The contents of the Measurement Units Code Sequence (0040,08EA) macro are mapped to the unit component of the PQ data type (UCUM codes are used for the CS data type): unit of measure code value as code property

Tables A.5.1.3-4 to A.5.1.3-6 list the code value and code meaning of SNOMED codes contained in DICOM context groups 7470 to 7472 and corresponding attribute values of SNOMED observable entity codes for DICOM SR TID 2000 based diagnostic imaging reports. For the latter codes SNOMED Concept IDs are used as code values.

Table A.5.1.3-4 TID 2000 LINEAR MEASUREMENT SNOMED CODE MAPPING FOR DICOM CONTEXT GROUP 7470

Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) Code Value of Equivalent Observable Entity Code (Concept ID) Code Meaning of Equivalent Observable Entity Code
SRT G-A22A Length 439932008 Length of structure
SRT G-A220 Width 440357003 Width of structure
SRT G-D785 Depth 439934009 Depth of structure
SRT M-02550 Diameter 439984002 Diameter of structure
SRT G-A185 Long Axis 439933003 Long axis length of structure
SRT G-A186 Short Axis 439428006 Short axis length of structure
SRT G-A193 Major Axis 439982003 Major axis length of structure
SRT G-A194 Minor Axis 439983008 Minor axis length of structure
SRT G-A195 Perpendicular Axis 440356007 Perpendicular axis length of structure
SRT G-A196 Radius 439429003 Radius of structure
SRT G-A197 Perimeter 440433004 Perimeter of non-circular structure
SRT M-02560 Circumference 439747008 Circumference of circular structure
SRT G-A198 Diameter of circumscribed circle 439748003 Diameter of circular structure

Table A.5.1.3-5

TID 2000 AREA MEASUREMENT SNOMED CODE MAPPING FOR DICOM CONTEXT GROUP 7471

Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) Code Value of Equivalent Observable Entity Code (Concept ID) Code Meaning of Equivalent Observable Entity Code
SRT G-A166 Area 439746004 Area of structure
SRT G-A16A Area of defined region 439985001 Area of body region

Table A.5.1.3-6

TID 2000 VOLUME MEASUREMENT SNOMED CODE MAPPING FOR DICOM CONTEXT GROUP 7472

Coding Scheme Designator (0008,0102) Code Value (0008,0100) Code Meaning (0008,0104) Code Value of Equivalent Observable Entity Code (Concept ID) Code Meaning of Equivalent Observable Entity Code
SRT G-D705 Volume 439749006 Volume of structure

Subject Act Relationship (QuantityMeasurement to SopInstance)

Equivalent DICOM relationship types of the CDA SUBJ actRelationship in this context are: INFERRED FROM and R-INFERRED. CDA Release 2 does not specify reference relationships. However act class clones that carry a unique identifier only and omit other attribut values of the original act class may be used to that purpose.

The relation of quantity measurements to procedures and acts is specified in section A.5.1.4.2 Procedure Context.

[pic]

Figure A.5.1.3-3: QUANTITY MEASUREMENT AND DICOM COMPOSITE OBJECT REFERENCE

The act relationships shown in figure A.5.1.3-3 are encoded as entryRelationships in CDA; the act classes are represented as observations.

DICOM SR numeric measurements (value type NUM) are mapped to the QuantityMeasurement act class.

The QuantityMeasurement act class is associated with one or more SopInstance act classes. SopInstance is associated with zero or one PurposeOfReference act class through the reason entry relationship.

Multi-frame Image References

The DICOM Image Reference Macro (used for SR content items of value type IMAGE) allows for referencing individual frames of a multi-frame image if the reference does not apply to all frames. The individual referenced frames (DICOM attribute “Referenced Frame Number” (0008,1160)) are mapped to the value attribute (list of integers) of the boundary act class. For mapping quantity measurements (applies to SR template 1400, 1401, 1402 and 1404) that are related to frames of a multi-frame image, one ReferencedFrames act class is associated with SopInstance through an entryRelationship of type code component (Figure A.5.1.3-3). The DICOM code 121190 “ReferencedFrames” is assigned to the ReferencedFrames.code attribute. The ReferencedFrames act class is related to one Boundary act class through an entryRelationship of type code component. In the context of mapping DICOM template 2000 the Boundary.value attribute contains the referenced frame number of the frame that is the basis for measurements or coded purpose of reference terms.

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.

[pic]

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.

[pic]

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.

[pic]

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.

[pic]

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).

[pic]

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.