C.17 SR Document Modules

C.17.1 SR Document Series Module

Table C.17-1 defines the Attributes of the SR Document Series. A Series of SR Documents may contain any number of SR Documents.

Note: Series of SR Documents are separate from Series of Images or other Composite SOP Instances. SR Documents do not reside in a Series of Images or other Composite SOP Instances.

Table C.17-1SR DOCUMENT SERIES MODULE ATTRIBUTES

Attribute Name Tag Type Attribute Description
Modality (0008,0060) 1 Modality type. Enumerated Value: SR = SR Document
Series Instance UID (0020,000E) 1 Unique identifier of the Series. Note: No SR-specific semantics are specified.
Series Number (0020,0011) 1 A number that identifies the Series. Note: No SR-specific semantics are specified.
Series Date (0008,0021) 3 Date the Series started.
Series Time (0008,0031) 3 Time the Series started.
Series Description (0008,103E) 3 Description of the Series
Series Description Code Sequence (0008,103F) 3 A coded description of the Series. Only a single Item is permitted in this sequence.
>Include Code Sequence Macro Table 8.8-1 No Baseline Context ID is defined.
Referenced Performed Procedure Step Sequence (0008,1111) 2 Uniquely identifies the Performed Procedure Step SOP Instance for which the Series is created. Zero or one item shall be included in this sequence. Notes: 1. The Performed Procedure Step referred to by this Attribute is the Step during which this Document is generated. 2. If this Document is generated during the same Modality or General Purpose Performed Procedure Step as the evidence in the current interpretation procedure, this attribute may contain reference to that Modality or General Purpose Performed Procedure Step. 3. This Attribute is not used to convey reference to the evidence in the current interpretation procedure. See Current Requested Procedure Evidence Sequence (0040,A375). 4. This Sequence may be sent zero length if the Performed Procedure Step is unknown.
>Include ‘SOP Instance Reference Macro' Table 10-11

C.17.2 SR Document General Module

Table C.17-2 defines the general Attributes of an SR Document Instance. These Attributes identify the SR Document and provide context for the entire document.

Table C.17-2SR DOCUMENT GENERAL MODULE ATTRIBUTES

Attribute Name Tag Type Attribute Description
Instance Number (0020,0013) 1 A number that identifies the SR Document.
Preliminary Flag (0040,A496) 3 Indicates whether this SR Document is intended to be regarded as a preliminary or final report. Enumerated Values: PRELIMINARY - this report precedes the final report and may contain limited information; it may be time sensitive, and it is not expected to contain all the reportable findings FINAL - this report is the definitive means of communicating the results of a procedure Note: The definitions of the enumerated values are derived from the ACR Practice Guideline For Communication Of Diagnostic Imaging Findings, Revised 2005.
Completion Flag (0040,A491) 1 The estimated degree of completeness of this SR Document with respect to externally defined criteria in a manner specified in the Conformance Statement. Notes: 1. It may be desirable to make these criteria adaptable to local policies or user decisions. 2. The concept of “completeness is independent of the concept of preliminary or final; see the description of Preliminary Flag (0040,A496). Enumerated Values: PARTIAL = Partial content. COMPLETE = Complete content.
Completion Flag Description (0040,A492) 3 Explanation of the value sent in Completion Flag (0040,A491).
Verification Flag (0040,A493) 1 Indicates whether this SR Document is Verified. Enumerated Values: UNVERIFIED = Not attested to. VERIFIED = Attested to by a Verifying Observer Name (0040,A075) who is accountable for its content. A value of “VERIFIED” shall be used only when the value of Completion Flag (0040,A491) is “COMPLETE”. Note: The intent of this specification is that the "prevailing final version" of an SR Document is the version having the most recent Verification DateTime (0040,A030), Verification Flag (0040,A493) of VERIFIED and Preliminary Flag (0040,A496) of FINAL.
Content Date (0008,0023) 1 The date the document content creation started.
Content Time (0008,0033) 1 The time the document content creation started.
Verifying Observer Sequence (0040,A073) 1C The person or persons authorized to verify documents of this type and accept responsibility for the content of this document. One or more Items shall be included in this sequence. Required if Verification Flag (0040,A493) is VERIFIED. Note: In HL7 Structured Documents, the comparable attribute is the “legalAuthenticator”.
>Verifying Observer Name (0040,A075) 1 The person authorized by the Verifying Organization (0040,A027) to verify documents of this type and who accepts responsibility for the content of this document.
>Verifying Observer Identification Code Sequence (0040,A088) 2 Coded identifier of Verifying Observer. Zero or one Item shall be included in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID defined.
>Verifying Organization (0040,A027) 1 Organization to which the Verifying Observer Name (0040,A075) is accountable in the current interpretation procedure.
>Verification DateTime (0040,A030) 1 Date and Time of verification by the Verifying Observer Name (0040,A075).
Author Observer Sequence (0040,A078) 3 The person or device that created the clinical content of this document. This attribute sets the default Observer Context for the root of the content tree. One or more Items are permitted in this sequence.
>Include 'Identified Person or Device Macro' Table C.17-3b
Participant Sequence (0040,A07A) 3 Persons or devices related to the clinical content of this document. One or more Items are permitted in this sequence.
>Participation Type (0040,A080) 1 Participant’s role with respect to the clinical content of this document. See C.17.2.5. Defined Terms: SOURCE - Equipment that contributed to the content ENT - Data enterer (e.g., transcriptionist) ATTEST - Attestor Note: In HL7 Structured Documents, the participation comparable to Attestor is the “Authenticator”.
>Participation DateTime (0040,A082) 2 DateTime of participation with respect to the clinical content of this document.
>Include 'Identified Person or Device Macro' Table C.17-3b
Custodial Organization Sequence (0040,A07C) 3 Custodial organization for this SR Document instance. Represents the organization from which the document originates and that is in charge of maintaining the document, i.e., the steward of the original source document. Note: This may or may not be identical to the Institution identified in the Equipment Module. Only a single item is permitted in this sequence.
>Institution Name (0008,0080) 2 Name of Custodial Institution or Organization.
>Institution Code Sequence (0008,0082) 2 Coded identifier of Custodial Institution or Organization. Zero or one Item shall be included in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID defined.
Predecessor Documents Sequence (0040,A360) 1C Shall refer to SR SOP Instances (e.g. prior or preliminary reports) whose content has been wholly or partially included in this document with or without modification. One or more Items shall be included in this sequence. Required if this document includes content from other documents. Note: The amendment process of an existing SR Document may be described using the Purpose of Reference Code Sequence.
>Include 'Hierarchical SOP Instance Reference Macro' Table C.17-3 Defined Context ID for the Purpose of Reference Code Sequence in the Hierarchical SOP Instance Reference Macro is CID 7009.
Identical Documents Sequence (0040,A525) 1C Duplicates of this document, stored with different SOP Instance UIDs. One or more Items shall be included in this sequence. Required if this document is stored with different SOP Instance UIDs in one or more other Studies. See C.17.2.2 for further explanation.
>Include 'Hierarchical SOP Instance Reference Macro' Table C.17-3
Referenced Request Sequence (0040,A370) 1C Identifies Requested Procedures which are being fulfilled (completely or partially) by creation of this Document. One or more Items shall be included in this sequence. Required if this Document fulfills at least one Requested Procedure. May be present otherwise.
>Study Instance UID (0020,000D) 1 Unique identifier for the Study.
>Referenced Study Sequence (0008,1110) 2 Uniquely identifies the Study SOP Instance. Zero or one Item shall be included in this sequence.
>> Include ‘SOP Instance Reference Macro' Table 10-11
>Accession Number (0008,0050) 2 A departmental IS generated number which identifies the order for the Study.
>Issuer of Accession Number Sequence (0008,0051) 3 Identifier of the Assigning Authority that issued the Accession Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Placer Order Number/Imaging Service Request (0040,2016) 2 The order number assigned to the Imaging Service Request by the party placing the order.
>Order Placer Identifier Sequence (0040,0026) 3 Identifier of the Assigning Authority that issued the Placer Order Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Filler Order Number/Imaging Service Request (0040,2017) 2 The order number assigned to the Imaging Service Request by the party filling the order.
>Order Filler Identifier Sequence (0040,0027) 3 Identifier of the Assigning Authority that issued the Filler Order Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Requested Procedure ID (0040,1001) 2 Identifier of the related Requested Procedure
>Requested Procedure Description (0032,1060) 2 Institution-generated administrative description or classification of Requested Procedure.
>Requested Procedure Code Sequence (0032,1064) 2 A sequence that conveys the requested procedure. Zero or one Item shall be included in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID Number is specified.
>Reason for the Requested Procedure (0040,1002) 3 Reason for requesting this procedure.
>Reason for Requested Procedure Code Sequence (0040,100A) 3 Coded Reason for requesting this procedure. One or more Items are permitted in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID Number is specified.
Performed Procedure Code Sequence (0040,A372) 2 A Sequence that conveys the codes of the performed procedures pertaining to this SOP Instance. Zero or more Items shall be included in this sequence.
>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID Number is specified.
Current Requested Procedure Evidence Sequence (0040,A375) 1C Full set of Composite SOP Instances, of which the creator is aware, which were created to satisfy the current Requested Procedure(s) for which this SR Document is generated or that are referenced in the content tree. One or more Items shall be included in this sequence. Required if the creator is aware of Composite Objects acquired in order to satisfy the Requested Procedure(s) for which the SR Document is or if instances are referenced in the content tree. May be present otherwise. See C.17.2.3 for further explanation.
>Include 'Hierarchical SOP Instance Reference Macro' Table C.17-3
Pertinent Other Evidence Sequence (0040,A385) 1C Other Composite SOP Instances that are considered to be pertinent evidence by the creator of this SR Document. This evidence must have been acquired in order to satisfy Requested Procedures other than the one(s) for which this SR Document is generated. One or more Items shall be included in this sequence. Required if pertinent evidence from other Requested Procedures needs to be recorded. See C.17.2.3 for further explanation.
>Include 'Hierarchical SOP Instance Reference Macro' Table C.17-3
Referenced Instance Sequence (0008,114A) 1C Sequence specifying SOP Instances significantly related to the current SOP Instance. Such referenced Instances may include equivalent documents or renderings of this document. One or more Items shall be included in this sequence. Required if the identity of a CDA Document equivalent to the current SOP Instance is known at the time of creation of this SOP Instance (see C.17.2.6). May be present otherwise.
>Include ‘SOP Instance Reference Macro' Table 10-11
>Purpose of Reference Code Sequence (0040,A170) 1 Code describing the purpose of the reference to the Instance(s). Only a single Item shall be included in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 Defined CID 7006.

C.17.2.1 Hierarchical SOP Instance Reference Macro

Table C.17-3 specifies the Attributes that reference a list of SOP Instances.

Table C.17-3

HIERARCHICAL SOP INSTANCE REFERENCE MACRO ATTRIBUTES

Attribute Name Tag Type Attribute Description
Study Instance UID (0020,000D) 1 Unique identifier for the Study
Referenced Series Sequence (0008,1115) 1 Sequence of Items where each Item includes the Attributes of a Series containing referenced Composite Object(s). One or more Items shall be included in this sequence
>Include ‘Hierarchical Series Reference Macro’ Table C.17-3a

Table C.17-3a specifies the Attributes that reference a Series of SOP Instances.

Table C.17-3a

HIERARCHICAL SERIES REFERENCE MACRO ATTRIBUTES

Series Instance UID (0020,000E) 1 Unique identifier of a Series that is part of this Study and contains the referenced Composite Object(s).
Retrieve AE Title (0008,0054) 3 Title of the DICOM Application Entity where the Composite Object(s) may be retrieved on the network.
Retrieve Location UID (0040, E011) 3 Unique identifier of the system where the Composite Object(s) may be retrieved on the network.
Storage Media File-Set ID (0088,0130) 3 The user or implementation specific human readable identifier that identifies the Storage Media on which the Composite Object (s) reside.
Storage Media File-Set UID (0088,0140) 3 Uniquely identifies the Storage Media on which the Composite Object (s) reside.
Referenced SOP Sequence (0008,1199) 1 References to Composite Object SOP Class/SOP Instance pairs that are part of the Study defined by Study Instance UID and the Series defined by Series Instance UID (0020,000E). One or more Items shall be included in this sequence.
>Include ‘SOP Instance Reference Macro' Table 10-11
>Purpose of Reference Code Sequence (0040,A170) 3 Describes the purpose for which the reference is made. One or more Items are permitted in this sequence.
>>Include ‘Code Sequence Macro’ Table 8.8-1 Baseline Context ID may be specified in Macro invocation.
>Referenced Digital Signature Sequence (0400,0402) 3 Sequence of references to Digital Signatures in the referenced SOP Instance. One or more Items are permitted in this sequence. Note: The Attributes in this sequence can be used to detect if the referenced SOP Instance has been altered.
>>Digital Signature UID (0400,0100) 1 The Unique Identifier of a Digital Signature held in the referenced SOP Instance.
>>Signature (0400,0120) 1 The Signature Value identified by the Digital Signature UID within the Referenced SOP Instance UID.
>Referenced SOP Instance MAC Sequence (0400,0403) 3 A MAC Calculation from data in the referenced SOP Instance that can be used as a data integrity check. Only a single Item is permitted in this Sequence. Note: This Attribute may be used in place of the Referenced Digital Signature Sequence Attribute (0400,0402), particularly if the SOP Instance does not have appropriate Digital Signatures that can be referenced.
>>MAC Calculation Transfer Syntax UID (0400,0010) 1 The Transfer Syntax UID used to encode the values of the Data Elements included in the MAC calculation. When computing the MAC, only Transfer Syntaxes that explicitly include the VR and use Little Endian encoding shall be used. Notes: 1. Certain Transfer Syntaxes, particularly those that are used with compressed data, allow the fragmentation of the pixel data to change. If such fragmentation changes, Digital Signatures generated with such Transfer Syntaxes could become invalid. 2. This does not constrain the transfer syntax used to transmit the object.
>>MAC Algorithm (0400,0015) 1 The algorithm used in generating the MAC. Defined Terms: RIPEMD160 MD5 SHA1 SHA256 SHA384 SHA512 Note: Digital Signature Security Profiles (see PS 3.15) may require the use of a restricted subset of these terms.
>>Data Elements Signed (0400,0020) 1 A list of Data Element Tags in the order they appear at the top level of the referenced SOP Instance that identify the Data Elements used in creating the MAC. See Section C.12.1.1.3.1.1.
>>MAC (0400,0404) 1 The MAC generated as described in Section 12.2.1.1, but unencrypted and without inclusion of fields from the Digital Signatures Sequence. See Section C.12.1.1.3.1.2.

C.17.2.2 Identical Documents Sequence

If identical copies of an SR Document are to be included in multiple Studies then the entire SR Document shall be duplicated with appropriate changes for inclusion into the different Studies (i.e. Study Instance UID, Series Instance UID, SOP Instance UID, Identical Documents Sequence etc.). The Identical Documents Sequence Attribute in each SOP Instance shall contain references to all other duplicate SOP Instances.

Note: If an SR Document contains an Identical Documents Sequence then it will not be further duplicated without producing a new complete set of duplicate SOP Instances with re-generated Identical Documents Sequences. This is a consequence of the rules for modification of SR Document content in PS3.4. For example, if there are two identical reports and an application is creating a third identical report, then the first two reports must be re-generated in order that their Identical Documents Sequence will reference the new duplicate document and all other identical documents.

If a new SR Document is created using content from an SR Document that contains an Identical Documents Sequence and is part of the same Requested Procedure, then the new SR Document shall only contain a new Identical Documents Sequence if the new SR Document is duplicated. The Predecessor Documents Sequence in all the new SR Documents shall contain references to the original SR Document and all its duplicates as well as any other documents from which content is included.

Note: It is up to an implementation to decide whether a new SR Document is duplicated across multiple Studies. This may require user input to make the decision.

C.17.2.3 Current Requested Procedure Evidence Sequence and Pertinent Other Evidence Sequence

The intent of the Current Requested Procedure Evidence Sequence (0040,A375) is to reference all evidence created in order to satisfy the current Requested Procedure(s) for this SR Document. This shall include, but is not limited to, all current evidence referenced in the content tree.

For a completed SR Document satisfying (i.e., being the final report for) the current Requested Procedure(s), this sequence shall list the full set of Composite SOP Instances created for the current Requested Procedure(s). For other SOP Instances that include the SR Document General Module, this sequence shall contain at minimum the set of Composite SOP Instances from the current Requested Procedure(s) that are referenced in the content tree.

The Pertinent Other Evidence Sequence (0040,A385) attribute is used to reference all other evidence considered pertinent for this SR Document that is not listed in the Current Requested Procedure Evidence Sequence (0040,A375).

This requires that the same SOP Instance shall not be referenced in both of these Sequences.

For the purposes of inclusion in the Current Requested Procedure Evidence Sequence (0040,A375) and the Pertinent Other Evidence Sequence (0040,A385), the set of Composite SOP Instances is defined to include not only the images and waveforms referenced in the content tree, but also all presentation states, real world value maps and other accompanying composite instances that are referenced from the content items.

C.17.2.4 Identified Person or Device Macro

Table C.17-3b defines the Attributes that identify a person or a device participating as an observer for the context of an SR Instance. This macro contains content equivalent to TID 1002 (see PS3.16).

Table C.17-3bIdentified Person or Device Macro Attributes

Attribute Name Tag Type Attribute Description
Observer Type (0040,A084) 1 Enumerated Values: PSN - Person DEV - Device
Person Name (0040,A123) 1C Name of the person observer for this document Instance. Required if Observer Type value is PSN.
Person Identification Code Sequence (0040,1101) 2C Coded identifier of person observer. Zero or one Item shall be included in this sequence. Required if Observer Type value is PSN.
>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID defined
Station Name (0008,1010) 2C Name of the device observer for this document instance. Required if Observer Type value is DEV.
Device UID (0018,1002) 1C Unique identifier of device observer. Required if Observer Type value is DEV.
Manufacturer (0008,0070) 1C Manufacturer of the device observer. Required if Observer Type value is DEV.
Manufacturer’s Model Name (0008,1090) 1C Model Name of the device observer. Required if Observer Type value is DEV.
Institution Name (0008,0080) 2 Institution or organization to which the identified person is responsible or accountable, or which manages the identified device.
Institution Code Sequence (0008,0082) 2 Institution or organization to which the identified person is responsible or accountable, or which manages the identified device. Zero or one Item shall be included in this Sequence.
>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID defined

C.17.2.5 Verifying Observer, Author Observer, and Participant Sequences

The Verifying Observer Sequence (0040,A073), Author Observer Sequence (0040,A078), and Participant Sequence (0040,A07A) identify significant contributors to the SR document. The Author creates the clinical content of the document. The Verifying Observer verifies and accepts legal responsibility for the content. Other participants may include an Attestor, a person identified as a Participant who “signs” an SR document, but who does not have legal authority to verify the clinical content. E.g., an SR document may be authored and attested by a resident, and then verified by a staff physician; or a document may be authored by a CAD device and attested by a technologist, and then verified by a physician; or a technologist working with a measurement software package may be the author, the package is a Source participant, and the final content is verified by a physician.

An individual shall not be identified in both the Verifying Observer Sequence (as the legal authenticator) and in the Participant Sequence as an Attestor. An individual may be identified in both the Author Observer Sequence and either the Verifying Observer Sequence or the Participant Sequence.

The participation DateTime for the Verifying Observer is conveyed in Verification DateTime (0040,A030) within the Verifying Observer Sequence, for the Author Observer in the Observation DateTime (0040,A032) in the main Data Set (see C.17.3), and for other participants in Participation DateTime (0040,A082) within the Participant Sequence.

C.17.2.6 Equivalent CDA Document

The Referenced Instance Sequence (0008,114A) with a Purpose of Reference Code Sequence value of (121331, DCM, “Equivalent CDA Document”) identifies an HL7 Clinical Document Architecture (CDA) Document that contains clinical content equivalent to this SR Document SOP Instance. This referenced CDA Document may be a source document that was transformed to create this SR Document, or it may be a transcoding of the content created simultaneously for both the SR Document and the CDA Document.

Notes: 1. Reference to a CDA Document created as a transcoding of the SR Document subsequent to the creation of the SR SOP Instance would not be encodable in that SOP Instance.

2. There is no requirement that the transform or transcoding between DICOM SR and HL7 CDA be reversible. In particular, some attributes of the DICOM Patient, Study, and Series IEs have no corresponding standard encoding in the HL7 CDA Header, and vice versa. Such data elements, if transcoded, may need to be encoded in implementation-dependent “local markup” (in HL7 CDA) or private data elements (in DICOM SR) in an implementation-dependent manner; some such data elements may not be transcoded at all. It is a responsibility of the transforming application to ensure clinical equivalence.

3. Due to the inherent differences between DICOM SR and HL7 CDA, a transcoded document should have a different UID than the source document.

The Referenced SOP Instance UID (0008,1155) in Items of this Sequence is mapped to the native HL7 Instance Identifier through the HL7 Structured Document Reference Sequence (0040,A390) of the SOP Common Module (see Section C.12.1).

C.17.3 SR Document Content Module

This section specifies the Attributes contained in the SR Document Content Module. The Attributes in this Module convey the content of an SR Document.

Table C.17-4SR DOCUMENT CONTENT MODULE ATTRIBUTES

Attribute Name Tag Type Attribute Description
Include Document Content Macro Table C.17-5. with a Value Type (0040,A040) of CONTAINER
Include Document Relationship Macro Table C.17-6.

Table C.17-5DOCUMENT CONTENT MACRO ATTRIBUTES

Attribute Name Tag Type Attribute Description
Value Type (0040,A040) 1 The type of the value encoded in this Content Item. Defined Terms: TEXT NUM CODE DATETIME DATE TIME UIDREF PNAME COMPOSITE IMAGE WAVEFORM SCOORD SCOORD3D TCOORD CONTAINER See C.17.3.2.1 for further explanation.
Concept Name Code Sequence (0040,A043) 1C Code describing the concept represented by this Content Item. Also conveys the value of Document Title and section headings in documents. Only a single Item shall be included in this sequence. Required if Value Type (0040,A040) is TEXT, NUM, CODE, DATETIME, DATE, TIME, UIDREF or PNAME. Required if Value Type (0040,A040) is CONTAINER and a heading is present, or this is the Root Content Item. Note: That is, containers without headings do not require Concept Name Code Sequence Required if Value Type (0040,A040) is COMPOSITE, IMAGE, WAVEFORM, SCOORD, SCOORD3D or TCOORD, and the Purpose of Reference is conveyed in the Concept Name. See C.17.3.2.2 for further explanation.
>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID.
Text Value (0040,A160) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is TEXT. Text data which is unformatted and whose manner of display is implementation dependent. The text value may contain spaces, as well as multiple lines separated by either LF, CR, CR LF or LF CR, but otherwise no format control characters (such as horizontal or vertical tab and form feed) shall be present, even if permitted by the Value Representation of UT. The text shall be interpreted as specified by Specific Character Set (0008,0005) if present in the SOP Common Module. Note: The text may contain single or multi-byte characters and use code extension techniques as described in PS 3.5 if permitted by the values of Specific Character Set (0008,0005).
DateTime (0040,A120) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is DATETIME.
Date (0040,A121) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is DATE.
Time (0040,A122) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is TIME.
Person Name (0040,A123) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is PNAME.
UID (0040,A124) 1C This is the value of the Content Item. Required if Value Type (0040,A040) is UIDREF.
Include 'Numeric Measurement Macro' Table C.18.1-1 if and only if Value Type (0040,A040) is NUM.
Include 'Code Macro' Table C.18.2-1 if and only if Value Type (0040,A040) is CODE.
Include 'Composite Object Reference Macro' Table C.18.3-1 if and only if Value Type (0040,A040) is COMPOSITE.
Include 'Image Reference Macro' Table C.18.4-1 if and only if Value Type (0040,A040) is IMAGE.
Include 'Waveform Reference Macro' Table C.18.5-1 if and only if Value Type (0040,A040) is WAVEFORM.
Include 'Spatial Coordinates Macro' Table C.18.6-1 if and only if Value Type (0040,A040) is SCOORD.
Include ‘3D Spatial Coordinates Macro' Table C.18.9-1 if and only if Value Type (0040,A040) is SCOORD3D.
Include 'Temporal Coordinates Macro' Table C.18.7-1 if and only if Value Type (0040,A040) is TCOORD.
Include 'Container Macro' Table C.18.8-1 if and only if Value Type (0040,A040) is CONTAINER.

Table C.17-6DOCUMENT RELATIONSHIP MACRO ATTRIBUTES

Attribute Name Tag Type Attribute Description
Observation DateTime (0040,A032) 1C The date and time on which this Content Item was completed. For the purpose of recording measurements or logging events, completion time is defined as the time of data acquisition of the measurement, or the time of occurrence of the event. Required if the date and time are different from the Content Date (0008,0023) and Content Time (0008,0033) or the Observation DateTime (0040,A032) defined in higher items. May be present otherwise. Note: When Content Items are copied into successor reports, the Content Date (0008,0023) and Content Time (0008,0033) of the new report are likely to be different than the date and time of the original observation. Therefore this attribute may need to be included in any copied Content Items to satisfy the condition.
Content Sequence (0040,A730) 1C A potentially recursively nested Sequence of Items that conveys content that is the Target of Relationships with the enclosing Source Content Item. One or more Items shall be included in this sequence. Required if the enclosing Content Item has relationships. Notes: 1. If this Attribute is not present then the enclosing Item is a leaf. 2. The order of Items within this Sequence is semantically significant for presentation. See C.17.3.2.4 for further explanation.
>Relationship Type (0040,A010) 1 The type of relationship between the (enclosing) Source Content Item and the Target Content Item. IODs specify additional constraints on Relationships (including lists of Enumerated Values). Defined Terms: CONTAINS HAS PROPERTIES HAS OBS CONTEXT HAS ACQ CONTEXT INFERRED FROM SELECTED FROM HAS CONCEPT MOD See C.17.3.2.4 for further explanation.
>Include Document Relationship Macro Table C.17-6 if the Target Content Item is included by-value in the Source Content Item. The Macro shall not be present if the relationship is by-reference.
>Include Document Content Macro Table C.17-5 if the Target Content Item is included by-value in the Source Content Item. The Macro shall not be present if the relationship is by-reference.
>Referenced Content Item Identifier (0040,DB73) 1C An ordered set of one or more integers that uniquely identifies the Target Content Item of the relationship. The root Content Item is referenced by a single value of 1. Each subsequent integer represents an ordinal position of a Content Item in the Content Sequence (0040,A730) in which it belongs. The Referenced Content Item Identifier is the set of these ordinal positions along the by-value relationship path. The number of values in this Multi-Value Attribute is exactly the number of relationships traversed in the SR content tree plus one. Note: 1. See C.17.3.2.5. 2. Content Items are ordered in a Content Sequence starting from 1 as defined in VR of SQ (See PS 3.5). Required if the Target Content Item is denoted by-reference, i.e. the Document Relationship Macro and Document Content Macro are not included.

C.17.3.1 SR Document Content Tree

The Module consists of a single root Content Item that is the root of the SR Document tree. The root Content Item is of type CONTAINER, and its Content Sequence conveys either directly or indirectly through further nested Content Sequences, all of the other Content Items in the document. This root Content Item shall have a heading in the Concept Name Code Sequence (0040,A043) that conveys the title of the SR Document, i.e. the Document Title.

Figure C.17.3-1 depicts the relationship of SR Documents to Content Items and the relationships of Content Items to other Content Items and to Observation Context.

[pic]

Figure C.17.3-1SR Information Model

[pic]

Note: Whether or not relationships by-reference are allowed to ancestor Content Items, is specified in the IOD.

Figure C.17.3-2 - Example of an SR Content Tree (Informative)

C.17.3.2 Content Item Attributes

Each Content Item contains:

- name/value pair, consisting of

- a single Concept Name Code Sequence (0040,A043) that is the name of a name/value pair or a heading,

- a value (text, codes, etc.),

- references to images, waveforms or other composite objects, with or without coordinates,

- relationships to other Items, either

- by-value through nested Content Sequences, or

- by-reference.

C.17.3.2.1 Content Item Value Type

The value of the name/value pair is encoded with one of the Value Types defined in Table C.17.3-7 (the choice of which may be constrained by the IOD in which this Module is contained). The Value Type (0040,A040) attribute explicitly conveys the type of Content Item value encoding.

Table C.17.3-7VALUE TYPE DEFINITIONS

Value Type Concept Name Concept Value Description
TEXT Type of text, e.g. "Findings", or name of identifier, e.g. “Lesion ID” Textual expression of the concept Free text, narrative description of unlimited length. May also be used to provide a label or identifier value.
NUM Type of numeric value or measurement, e.g. "BPD" Numeric value and associated Unit of Measurement Numeric value fully qualified by coded representation of the measurement name and unit of measurement.
CODE Type of code, e.g. "Findings" Coded expression of the concept Categorical coded value. Representation of nominal or non-numeric ordinal values.
DATETIME Type of DateTime, e.g. "Date/Time of onset" Concatenated date and time Date and time of occurrence of the type of event denoted by the Concept Name.
DATE Type of Date, e.g. "Birth Date" Calendar date Date of occurrence of the type of event denoted by the Concept Name.
TIME Type of Time, e.g "Start Time" Time of day Time of occurrence of the type of event denoted by the Concept Name.
UIDREF Type of UID, e.g "Study Instance UID" Unique Identifier Unique Identifier (UID) of the entity identified by the Concept Name.
PNAME Role of person, e.g., "Recording Observer" Name of person Person name of the person whose role is described by the Concept Name.
COMPOSITE Purpose of Reference Reference to UIDs of Composite SOP Instances A reference to one Composite SOP Instance which is not an Image or Waveform.
IMAGE Purpose of Reference Reference to UIDs of Image Composite SOP Instances A reference to one Image. IMAGE Content Item may convey a reference to a Softcopy Presentation State associated with the Image.
WAVEFORM Purpose of Reference Reference to UIDs of Waveform Composite SOP Instances A reference to one Waveform.
SCOORD Purpose of Reference Listing of spatial coordinates Spatial coordinates of a geometric region of interest in the DICOM image coordinate system. The IMAGE Content Item from which spatial coordinates are selected is denoted by a SELECTED FROM relationship.
SCOORD3D Purpose of reference Listing of spatial 3D coordinates 3D spatial coordinates (x,y,z) of a geometric region of interest in a Reference Coordinate System.
TCOORD Purpose of Reference Listing of temporal coordinates Temporal Coordinates (i.e. time or event-based coordinates) of a region of interest in the DICOM waveform coordinate system. The WAVEFORM or IMAGE or SCOORD Content Item from which Temporal Coordinates are selected is denoted by a SELECTED FROM relationship.
CONTAINER Document Title or document section heading. Concept Name conveys the Document Title (if the CONTAINER is the Document Root Content Item) or the category of observation. The content of the CONTAINER. The value of a CONTAINER Content Item is the collection of Content Items that it contains. CONTAINER groups Content Items and defines the heading or category of observation that applies to that content. The heading describes the content of the CONTAINER Content Item and may map to a document section heading in a printed or displayed document.

Note: It is recommended that drawings and sketches, sometimes used in reports, be represented byIMAGE Content Items that reference separate SOP Instances (e.g., 8-bit, MONOCHROME2, Secondary Capture, or Multi-frame Single Bit Secondary Capture).

C.17.3.2.2 Concept Name Code Sequence

The Concept Name Code Sequence (0040,A043) conveys the name of the concept whose value is expressed by the value attribute or set of attributes. Depending on the Value Type (0040,A040), the meaning of the Concept Name Code Sequence may reflect specifics of the use of the particular data type (see Table C.17.3-7).

C.17.3.2.3 Continuity of Content

See Section C.18.8.1.1.

C.17.3.2.4 Content Sequence and Relationship Type

The Content Sequence (0040,A730) provides the hierarchical structuring of the Content Tree (see C.17.3.1) by recursively nesting Content Items. A parent (or source) Content Item has an explicit relationship to each child (or target) Content Item, conveyed by the Relationship Type (0040,A010) attribute.

Table C.17.3-8 describes the Relationship Types between Source Content Items and the Target Content Items.

Table C.17.3-8RELATIONSHIP TYPE DEFINITIONS

Relationship Type Description Definition and Example
CONTAINS Contains Source Item contains Target Content Item. E.g.: CONTAINER "History" {CONTAINS: TEXT “mother had breast cancer”, CONTAINS: IMAGE}
HAS OBS CONTEXT Has Observation Context Target Content Items shall convey any specialization of Observation Context needed for unambiguous documentation of the Source Content Item. E.g: CONTAINER "Report" {HAS OBS CONTEXT: PNAME “Recording Observer” = “Smith^John^^Dr^”}
HAS CONCEPT MOD Has Concept Modifier Used to qualify or describe the Concept Name of the Source Content item, such as to create a post-coordinated description of a concept, or to further describe a concept. E.g. CODE "Chest X-Ray" {HAS CONCEPT MOD: CODE "View = PA and Lateral"} E.g. CODE "Breast" {HAS CONCEPT MOD: TEXT "French Translation" = "Sein"} E.g. CODE "2VCXRPALAT" {HAS CONCEPT MOD: TEXT "Further Explanation" = "Chest X-Ray, Two Views, Postero-anterior and Lateral"}
HAS PROPERTIES Has Properties Description of properties of the Source Content Item. E.g: CODE "Mass" {HAS PROPERTIES: CODE “anatomic location”, HAS PROPERTIES: CODE “diameter”, HAS PROPERTIES: CODE “margin”, ...}.
HAS ACQ CONTEXT Has Acquisition Context The Target Content Item describes the conditions present during data acquisition of the Source Content Item. E.g: IMAGE {HAS ACQ CONTEXT: CODE “contrast agent”, HAS ACQ CONTEXT: CODE “position of imaging subject”, ...}.
INFERRED FROM Inferred From Source Content Item conveys a measurement or other inference made from the Target Content Items. Denotes the supporting evidence for a measurement or judgment. E.g: CODE "Malignancy" {INFERRED FROM: CODE "Mass", INFERRED FROM: CODE "Lymphadenopathy",...}. E.g: NUM: "BPD” = “5mm" {INFERRED FROM: SCOORD}.
SELECTED FROM Selected From Source Content Item conveys spatial or temporal coordinates selected from the Target Content Item(s). E.g: SCOORD "POLYLINE1,1 5,10 5,10 1,10 1,1" {SELECTED FROM: IMAGE}. E.g: TCOORD "SEGMENT 60-200mS" {SELECTED FROM: WAVEFORM}.

C.17.3.2.5 Referenced Content Item Identifier

Content Items are identified by their position in the Content Item tree. They have an implicit order as defined by the order of the Sequence Items. When a Content Item is the target of a by-reference relationship, its position is specified in the Referenced Content Item Identifier (0040,DB73) in a Content Sequence Item subsidiary to the source Content Item.

Note: Figure C.17.3-3 illustrates an SR content tree and identifiers associated with each Content Item:

[pic]

Figure C.17.3-3 Use of Position as SR Content Item Identifier (Informative)

C.17.4 SR Content Tree Example (Informative)

Figure C.17.4-1 depicts the content of an example diagnostic interpretation.

[pic]

Notes: 1. For nodes of type CONTAINER, the contents of the Concept Name Code Sequence are shown in quotes and italicized.

2. For nodes of Value Type CODE, PNAME, NUM the contents are shown as “ Concept Name Code Sequence = Value”.

3. For the nodes of Value Type IMAGE and SCOORD, the contents of the Concept Name Code Sequence indicating the purpose of reference are shown in quotes and italicized.

4. The root node containing the Document Type is illustrated using a post-coordinated node of "Chest X-Ray", qualified using a HAS CONCEPT MOD relationship by a child with a CODE meaning "Views = PA and Lateral". An alternative would be to use a single pre-coordinated code in one node that applies to the entire concept of a "Two-view (PA and Lateral) Chest X-Ray". However, the use of pre-coordinated terms to describe complex concepts rapidly becomes unwieldy and difficult to search on (in the sense that more specific pre-coordinated codes do not have a visible relationship with more general codes). If it were necessary to include a longer textual description of Document Type, then this could be achieved with a HAS CONCEPT MOD relationship with one or more TEXT nodes, perhaps in different languages.

5. The Document Type is only a title, and is not being used to convey the Procedure Context, although in this example it does appear to contain a description of some aspects of Procedure Context.

Figure C.17.4-1 (Informative)SR Content Tree for an Example Diagnostic Interpretation

C.17.5 Observation Context Encoding

Observation Context describes who or what is performing the interpretation (observer context), whether the examination of evidence is direct or quoted (quotation mode), what procedure generated the evidence that is being interpreted (procedure context), and who or what is the subject of the evidence that is being interpreted (subject context).

Initial Observation Context is defined outside the SR Document Content tree by other modules in the SR IOD. The Patient Module specifies the default Subject Context, the General Study Module specifies the default Procedure Context, and the SR Document General Module specifies the default Observer Context. The default context has the meaning “this Structured Report was produced by the observer identified in the SR Document General module, using direct observation, for the procedure identified in the General Study Module, and is about the patient identified in the Patient Module.” Observation Context defined by attributes in these modules applies to all Content Items in the SR Document Content tree and need not be explicitly coded in the tree. The initial Observation Context from outside the tree can be explicitly replaced for the entire tree, or for any sub-tree.

Observer Context is set from the Author Observer Sequence (0040,A078), if present, or secondarily from the Verifying Observer Sequence (0040,A073). If neither is present, the Observer Context is undefined.

Note: In the absence of Observer Context, it may be presumed that the observations were generated by or with the equipment identified in the General Equipment Module.

The Procedure Context is set from the Study Instance UID (0020,000D), Study ID (0020,0010), Accession Number (0008,0050), and Procedure Code Sequence (0008,1032) of the General Study Module. The Referenced Request Sequence (0040,A370) might include an Item with the same Study Instance UID that further elaborates the Procedure Context, e.g., providing Placer Order Number (0040,2016) and/or Filler Order Number (0040,2017). If the Referenced Request Sequence includes Items with different Study Instance UIDs, those shall be treated as Procedure Context only if explicitly encoded in the Content Tree.

Medical or clinical characteristics of the patient specified in the Patient Study Module, such as in attributes Patient’s Size (0010,1020) and Patient’s Weight (0010,1030), shall not be inherited by the Content Tree as part of the default Patient Context. Such characteristics must be specifically encoded in the Content Tree to be part of the Structured Report.

Note: The Patient Study Module may be included in SR SOP Instances. As part of the Study IE shared by all SOP Instances within a Study, such inclusion should be consistent across all Instances. However, its purpose is to provide a minimum set of clinical context for the (initial) interpretation of the images or waveforms of the study. An SR SOP Instance that documents the interpretation must explicitly describe the relevant clinical context in the SR Content Tree.

If a Content Item in the SR Document Content tree has Observation Context different from the initial context already encoded elsewhere in the IOD, the context information applying to that Content Item shall be encoded as child nodes of the Content Item in the tree using the HAS OBS CONTEXT relationship. That is, Observation Context is a property of its parent Content Item.

The context information specified in the Observation Context child nodes (i.e. target of the HAS OBS CONTEXT relationship) sets the Observation Context of their parent node Content item. Observation Context is encoded in the same manner as any other Content Item.

The Observation Context applies to all the by-value descendant nodes of that parent node regardless of the relationship type between the parent and the descendant nodes, until and unless the context of a descendant node is reset by other Observation Context Content Items. Observation Context shall not be inherited across by-reference relationships. The four dimensions of Observation Context (observer context, quotation mode, procedure context, and subject context) may be reset independently; e.g., resetting the subject context does not reset the observer or procedure context, or the quotation mode. See the example in Figure C.17.5-1.

Note: For example, the “subject context” may be defined by attaching an appropriate content item to the root node with a HAS OBS CONTEXT relationship. This “subject context” then applies not only to the root node, but to all its descendants, until such time as a content item explicitly replaces the “subject context” attribute, the new value of which is then inherited by all of that nodes descendants.

Observation DateTime is not included as part of the HAS OBS CONTEXT relationship, and therefore is not inherited along with other Observation Context. The Observation DateTime Attribute is included in each Content Item which allows different observation dates and times to be attached to different Content Items.

The IOD may specify restrictions on Content Items and Relationship Types that also constrain the flexibility with which Observation Context may be described.

The IOD may specify Templates that offer or restrict patterns and content in Observation Context.

[pic]

Notes: 1. Node 2 inherits any Observation Context of Node 1, which is then extended or replaced by the additional Observation Context defined in Nodes C1 and C2 (that is C1 and C2 are properties of 2).

2. Node 3 and its descendents inherit the Observation Context of Node 2, which includes C1 and C2.

3. Node 4 inherits the Observation Context of Node 2, which includes C1 and C2.

Figure C.17.5-1 (Informative)Definition and Inheritance of Observation Context

C.17.6 Key Object Selection Modules

C.17.6.1 Key Object Document Series Module

Table C.17.6-1 defines the Attributes of the Key Object Document Series.

Note: Series of Key Object Selection Documents are separate from Series of Images or other Composite SOP Instances. Key Object Documents do not reside in a Series of Images or other Composite SOP Instances.

Table C.17.6-1KEY OBJECT DOCUMENT SERIES MODULE ATTRIBUTES

Attribute Name Tag Type Attribute Description
Modality (0008,0060) 1 Modality type. Enumerated Value: KO = Key Object Selection
Series Instance UID (0020,000E) 1 Unique identifier of the Series. Note: No specific semantics are specified.
Series Number (0020,0011) 1 A number that identifies the Series. Note: No specific semantics are specified.
Series Date (0008,0021) 3 Date the Series started.
Series Time (0008,0031) 3 Time the Series started.
Series Description (0008,103E) 3 Description of the Series
Series Description Code Sequence (0008,103F) 3 A coded description of the Series. Only a single Item is permitted in this sequence.
>Include Code Sequence Macro Table 8.8-1 No Baseline Context ID is defined.
Referenced Performed Procedure Step Sequence (0008,1111) 2 Uniquely identifies the Performed Procedure Step SOP Instance for which the Series is created. Zero or one item shall be included in this sequence. Notes: See notes on this attribute in Section C.17.1 SR Document Series Module
>Include ‘SOP Instance Reference Macro' Table 10-11

C.17.6.2 Key Object Document Module

Table C.17.6-2 defines the general Attributes of a Key Object Selection Document. These Attributes identify and provide context for the Key Object Selection Document.

Table C.17.6-2KEY OBJECT DOCUMENT MODULE ATTRIBUTES

Attribute Name Tag Type Attribute Description
Instance Number (0020,0013) 1 A number that identifies the Document.
Content Date (0008,0023) 1 The date the document content creation started.
Content Time (0008,0033) 1 The time the document content creation started.
Referenced Request Sequence (0040,A370) 1C Identifies Requested Procedures to which this Document pertains. One or more Items shall be included in this sequence. Required if this Document pertains to at least one Requested Procedure.
>Study Instance UID (0020,000D) 1 Unique identifier for the Study.
>Referenced Study Sequence (0008,1110) 2 Uniquely identifies the Study SOP Instance. Zero or one Item shall be included in this sequence.
>>Include ‘SOP Instance Reference Macro' Table 10-11
>Accession Number (0008,0050) 2 A departmental IS generated number which identifies the order for the Study.
>Issuer of Accession Number Sequence (0008,0051) 3 Identifier of the Assigning Authority that issued the Accession Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Placer Order Number/Imaging Service Request (0040,2016) 2 The order number assigned to the Imaging Service Request by the party placing the order.
>Order Placer Identifier Sequence (0040,0026) 3 Identifier of the Assigning Authority that issued the Placer Order Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Filler Order Number/Imaging Service Request (0040,2017) 2 The order number assigned to the Imaging Service Request by the party filling the order.
>Order Filler Identifier Sequence (0040,0027) 3 Identifier of the Assigning Authority that issued the Filler Order Number. Only a single Item is permitted in this sequence.
>>Include HL7v2 Hierarchic Designator Macro Table 10-17
>Requested Procedure ID (0040,1001) 2 Identifier of the related Requested Procedure
>Requested Procedure Description (0032,1060) 2 Institution-generated administrative description or classification of Requested Procedure.
>Requested Procedure Code Sequence (0032,1064) 2 A sequence that conveys the requested procedure. Zero or one Item shall be included in this sequence.
>>Include 'Code Sequence Macro' Table 8.8-1 No Baseline Context ID Number is specified.
Current Requested Procedure Evidence Sequence (0040,A375) 1 List of all Composite SOP Instances referenced in the Content Sequence (0040,A730) , including all presentation states, real world value maps and other accompanying composite instances that are referenced from the content items. One or more Items shall be included in this sequence. Note: In the context of the Key Object Selection, the current evidence is considered to be only the set of instances referenced within the Key Object Selection.
>Include '’Hierarchical SOP Instance Reference Macro' Table C.17-3
Identical Documents Sequence (0040,A525) 1C Duplicates of this document, stored with different SOP Instance UIDs. One or more Items shall be included in this sequence. Required if this Key Object Selection document references instances in more than one Study. See C.17.2.2 and C.17.6.2.1 for further explanation and conditions.
>Include '’Hierarchical SOP Instance Reference Macro' Table C.17-3

C.17.6.2.1 Identical Documents

If the Current Requested Procedure Evidence Sequence (0040,A375) references SOP Instances both in the current study and in one or more other studies, this document shall be duplicated into each of those other studies, and the duplicates shall be referenced in the Identical Documents Sequence (0040,A525).

Note: Thus a Key Object Selection Document that references images in the current study as well as in a prior or comparison study, would be duplicated into the other study. This allows an application displaying that other study to easily access notes relevant to that study's SOP Instances.