C.2 Patient Modules

The following Sections specify Modules used for patient management.

C.2.1 Patient Relationship Module

Table C.2-1 defines the Attributes that reference SOP Instances related to this SOP Class.

Table C.2-1PATIENT RELATIONSHIP MODULE ATTRIBUTES

Attribute Name Tag Attribute Description
Referenced Study Sequence (0008,1110) Uniquely identifies the Study SOP Instances associated with the Patient SOP Instance. One or more Items shall be included in this Sequence.
>Include ‘SOP Instance Reference Macro' Table 10-11
Referenced Visit Sequence (0008,1125) Uniquely identifies the Visit SOP Instances associated with this Patient SOP Instance. One or more Items shall be included in this Sequence.
>Include ‘SOP Instance Reference Macro' Table 10-11
Referenced Patient Alias Sequence (0038,0004) Uniquely identifies any Patient SOP Instances that also describe this patient. These SOP Instances are aliases. Zero or more Items shall be included in this Sequence.
>Include ‘SOP Instance Reference Macro' Table 10-11

C.2.2 Patient Identification Module

Table C.2-2 defines the Attributes relevant to identifying a patient.

Table C.2-2PATIENT IDENTIFICATION MODULE ATTRIBUTES

Attribute Name Tag Attribute Description
Patient's Name (0010,0010) Patient's full name
Patient ID (0010,0020) Primary hospital identification number or code for the patient.
Include Issuer of Patient ID Macro Table 10-18
Other Patient IDs (0010,1000) Other identification numbers or codes used to identify the patient.
Other Patient IDs Sequence (0010,1002) A sequence of identification numbers or codes used to identify the patient, which may or may not be human readable, and may or may not have been obtained from an implanted or attached device such as an RFID or barcode.
>Patient ID (0010,0020) An identification number or code used to identify the patient
>Include Issuer of Patient ID Macro Table 10-18
>Type of Patient ID (0010,0022) The type of identifier in this item. Defined Terms: TEXT RFID BARCODE Note: The identifier is coded as a string regardless of the type, not as a binary value.
Other Patient Names (0010,1001) Other names used to identify the patient.
Patient's Birth Name (0010,1005) Patient's birth name.
Patient's Mother's Birth Name (0010,1060) Birth name of patient's mother.
Medical Record Locator (0010,1090) An identifier used to find the patient's existing medical record (e.g. film jacket).

C.2.3 Patient Demographic Module

Table C.2-3 defines the Attributes relevant to generally describing a patient at a specific point in time, e.g., at the time of admission.

Table C.2-3PATIENT DEMOGRAPHIC MODULE ATTRIBUTES

Attribute Name Tag Attribute Description
Patient's Age (0010,1010) Age of the Patient.
Occupation (0010,2180) Occupation of the Patient.
Confidentiality Constraint on Patient Data Description (0040,3001) Special indication to the modality operator about confidentiality of patient information (e.g., that he should not use the patients name where other patients are present).
Patient’s Birth Date (0010,0030) Date of birth of the named patient
Patient’s Birth Time (0010,0032) Time of birth of the named patient
Patient's Sex (0010,0040) Sex of the named patient. Enumerated Values: M = male F = female O = other
Patient's Insurance Plan Code Sequence (0010,0050) A sequence that conveys the patient's insurance plan. Zero or more Items shall be included in this Sequence.
>Include ‘Code Sequence Macro’ Table 8.8-1 No Baseline Context ID is defined.
Patient’s Primary Language Code Sequence (0010,0101) The languages that can be used to communicate with the patient. Zero or more Items shall be included in this sequence. The sequence items are ordered by preference (most preferred language to least preferred language).
>Include Code Sequence Macro Table 8.8-1 Baseline CID 5000 - Languages.
>Patient’s Primary Language Modifier Code Sequence (0010,0102) A modifer for a Patient’s Primary Language. Can be used to specify a national language variant. Only a single Item shall be included in this sequence.
>>Include Code Sequence Macro Table 8.8-1 Baseline CID 5001 - Countries.
Patient's Size (0010,1020) Patient's height or length in meters
Patient's Weight (0010,1030) Weight of the patient in kilograms
Patient's Size Code Sequence (0010,1021) Patient's size category code One or more Items are permitted in this sequence.
> Include Code Sequence Macro Table 8.8-1 Baseline Context ID is CID 7040 for pediatric patients
Patient’s Address (0010,1040) Legal address of the named patient
Military Rank (0010,1080) Military rank of patient
Branch of Service (0010,1081) Branch of the military. The country allegiance may also be included (e.g. U.S. Army).
Country of Residence (0010,2150) Country in which patient currently resides
Region of Residence (0010,2152) Region within patient's country of residence
Patient’s Telephone Numbers (0010,2154) Telephone numbers at which the patient can be reached
Ethnic Group (0010,2160) Ethnic group or race of patient
Patient's Religious Preference (0010,21F0) The religious preference of the patient
Patient Comments (0010,4000) User-defined comments about the patient
Responsible Person (0010,2297) Name of person with medical decision making authority for the patient.
Responsible Person Role (0010,2298) Relationship of Responsible Person to the patient. See Section C.7.1.1.1.2 for Defined Terms.
Responsible Organization (0010,2299) Name of organization with medical decision making authority for the patient.
Patient Species Description (0010,2201) The species of the patient.
Patient Species Code Sequence (0010,2202) The species of the patient.
>Include ‘Code Sequence Macro’ Table 8.8-1 Defined CID 7454.
Patient Breed Description (0010,2292) The breed of the patient. See C.7.1.1.1.1.
Patient Breed Code Sequence (0010,2293) The breed of the patient. See C.7.1.1.1.1.
>Include ‘Code Sequence Macro’ Table 8.8-1 Defined CID 7480.
Breed Registration Sequence (0010,2294) Information identifying an animal within a breed registry.
>Breed Registration Number (0010,2295) Identification number of a veterinary patient within the registry.
>Breed Registry Code Sequence (0010,2296) Identification of the organization with which an animal is registered.
>>Include ‘Code Sequence Macro’ Table 8.8-1 Defined CID 7481.

Note: The language codes specified in CID 5000, used in Patient’s Primary Language Code Sequence (0010,0101), optionally allow the encoding of the country of language in the code value for the language. Encoding of the country of language in a subsidiary Patient’s Primary Language Modifier Code Sequence (0010,0102) is allowed for backward compatibility with previous editions of the Standard.

C.2.4 Patient Medical Module

Table C.2-4 defines the Attributes relevant to a patient's medical state or history.

Table C.2-4PATIENT MEDICAL MODULE ATTRIBUTES

Attribute Name Tag Attribute Description
Medical Alerts (0010,2000) Conditions to which medical staff should be alerted (e.g. contagious condition, drug allergies, etc.)
Allergies (0010,2110) Description of prior reaction to contrast agents, or other patient allergies or adverse reactions.
Smoking Status (0010,21A0) Indicates whether patient smokes. Enumerated Values: YES NO UNKNOWN
Additional Patient History (0010,21B0) Additional information about the patient's medical history
Pregnancy Status (0010,21C0) Describes pregnancy state of patient. Enumerated Values: 0001 = not pregnant 0002 = possibly pregnant 0003 = definitely pregnant 0004 = unknown
Last Menstrual Date (0010,21D0) Date of onset of last menstrual period
Patient’s Sex Neutered (0010,2203) Whether or not a procedure has been performed in an effort to render the patient sterile. Enumerated value: ALTERED = Altered/Neutered UNALTERED = Unaltered/intact
Special Needs (0038,0050) Medical and social needs (e.g. wheelchair, oxygen, translator, etc.)
Patient State (0038,0500) Description of patient state (comatose, disoriented, vision impaired, etc.)
Pertinent Documents Sequence (0038,0100) List of Documents (e.g., SR, or CDA) that contain information considered pertinent for the patient medical condition. Zero or more Items shall be included in this sequence.
>Include SOP Instance Reference Macro Table 10-11
>Purpose of Reference Code Sequence (0040,A170) Describes the purpose for which the document reference is made. Zero or more Items shall be included in this sequence.
>>Include ‘Code Sequence Macro’ Table 8.8-1 No Baseline Context Group ID defined
>Document Title (0042,0010) Title of the referenced document.
Patient Clinical Trial Participation Sequence (0038,0502) Sequence of identifiers for clinical trials in which the patient participates. Zero or more Items shall be included in this sequence.
>Clinical Trial Sponsor Name (0012,0010) The name of the clinical trial sponsor, responsible for conducting the clinical trial and for defining the Clinical Trial Protocol.
>Clinical Trial Protocol ID (0012,0020) Identifier for the noted protocol, used by the Clinical Trial Sponsor to uniquely identify the investigational protocol.
>Clinical Trial Protocol Name (0012,0021) The name or title of the clinical trial protocol.
>Clinical Trial Site ID (0012,0030) The identifier, issued by the Clinical Trial Sponsor, of the site responsible for submitting clinical trial data.
>Clinical Trial Site Name (0012,0031) Name of the site responsible for submitting clinical trial data.
>Clinical Trial Subject ID (0012,0040) The assigned identifier for the patient as a clinical trial subject.
>Clinical Trial Subject Reading ID (0012,0042) Identifies the patient as a clinical trial subject for blinded evaluations.

Note: The Patient Clinical Trial Participation Sequence (0038,0502) identifies potentially multiple trials in which the patient is enrolled. Application behavior in the presence of multiple items is outside the scope of the standard.