Supplement nnn: National Radiology Report
Page 1
Digital Imaging and Communications in Medicine (DICOM)
Supplement 150: National Radiology Report
Prepared by: WG-20
DICOM Standards Committee, Working Group 6, Base Standard
1300 N. 17th Street, Suite 1847
Rosslyn, Virginia22209USA
Version: Draft Public Comment 08
November 26, 2009
Table of Contents
Document History
Open Issues and Work To Do
Foreword
Scope and Field of Application
Changes to NEMA Standards Publication PS 3.16-2007
Item #1: Add new Section to Annex A
NATIONAL RADIOLOGY REPORT TEMPLATES
TID xxxx1 National Radiology Report
TID xxxx2Examination
TID xxxx3Medical Content
TID xxxx4Radiology Report Section Content
TID xxxx5National Extensions
TID xxxx6German Extension
TID xxxx7Information concerning the German X-Ray and Radiation Control Regulation
Item #2: Add the following Definitions to Annex D
Item #3: Extend the Context ID 7001
Item #4: Add a new Annex
Document History
Version / Date / Comments01 / July 11, 2007 / Created, draft distributed
02 / November 15, 2007 / Changes to PS 3.3 removed
03 / November 30, 2007 / Includes changes as result of the tecon November 20, 2007
04 / January 3, 2008 / Included template TID xx06 into template TID Tx10011 to make the overall base-structure of TID 2000 more clear.
Added a remark to row 7 of template TID xx01.
Acepted all changes made so far.
05 / April 2, 2008 / Reference to Radiation Dose Report added in Examination Section.
06 / June 12, 2008 / - Level of identation changed in TID xx01 and TID xx02
- Target region in TID xx03 may be included as text or code content item
- Modified TID xx06 “Radiology Report Section Content” for reuse of section content (identical to TID 2000 section content)
- TID xx01 and TID xx02 have been merged into single template TID xx01 that may contain information required by the German X-Ray or Radiation Control Regulation
07 / July 21, 2008 / - Template overview diagram has been added
- New templates and new codes have been renumbered
- Changed TID xxxx5 “German Extension” to extensible
- Mandatory information on “Performing Physician” and/or “Performing Technologist” will be provided as part of the observer context in the root template
08 / November, 2009 / - Changed report structure to allow for a variety of national extensions (description on scope and field has been adapted). Conditions for radiation exposure and radioactive substance administered have been modified to address hybrid imaging (e.g. PET/CT) where reporting of dose and activity of radioactive substances administered are required.
- Clarification on person observer mandatory attributes has been added.
- Changed TID xxxx1 “NATIONAL RADIOLOGY REPORT” type to non-extensible, TID xxxx2 “EXAMINATION” and TID xxxx3 “MEDICAL CONTENT” types to extensible.
- Clarification has been added that order of sections is not significant in TID xxxx3 “MEDICAL CONTENT”.
- Description of contents of TID xxxx3 “MEDICAL CONTENT” has been added.
Open Issues and Work To Do
# / Issue / To Do1 / Clarification needed if new context groups are needed for participants and observations that are part of the German extensions.
Foreword
This supplement to the DICOM standard introduces a template for National Radiology Report in DICOM. The concepts of Structured Reporting will be used in this context.
This document is a Supplement to the DICOM Standard. It is an extension to the following parts of the published DICOM Standard:
PS 3.16Content Mapping Resource
Scope and Field of Application
The National Radiology Report DICOM SR templates are based on the report structure and contents of PS 3.16 TID 2000 “Basic Diagnostic Imaging Report”.
Additional information is contained in sections that extend the basid TID 2000 structure and contents:
- The Examination section includes basic information on the current imaging procedure.
- The Medical Content section comprises relevant medical history data, information on the current request (i.e. clinical question that is expected to be answered by the requested procedure) and impressions on the current imaging procedure that has been performed.
- National Extensions allow for country-specific extensions that cover national documentation requirements such as summaries on the applied dose for imaging procedures using ionizing radiation.
To avoid discrepancies a close cooperation with WG-20 (Integration of Imaging and Information Systems) is aspired. A first evaluation of the draft gave no principal objections concerning the structure. Codes defined for use in the new template could be registered as external codes in CDA as well.
German Extension
German law requires written report for X-ray and nuclear medicine examinations.
The German X-Ray and Radiation Control Regulation („Röntgenverordnung“, „Strahlenschutzverordnung“) does not specify the content of the report.
The German national standard DIN 6827-5, „Recording in medical application of ionizing radiation – Part 5: Radiological report“ specifies the medical content of the report and gives the option to document radiation protection content.
„TID 2000 Basic Diagnostic Imaging Report“ defines only the skeletal structure of the report. TID 2000 does not require medical content or content concerning radiation protection.
The objective of this work item is the translation of DIN 6827-5 into a DICOM SR template.
To allow a flexible definition of the content a new template should be defined. The structure of the template should be similar to TID2000.
To avoid discrepancies a close cooperation with WG-20 (Integration of Imaging and Information Systems) is aspired. A first evaluation of the draft gave no principal objections concerning the structure. Codes defined for use in the new template could be registered as external codes in CDA as well.
Changes to NEMA Standards Publication PS 3.16-2007
Digital Imaging and Communications in Medicine (DICOM)
Part 16: Content Mapping Resource
Item #012: Add new Section to Annex A
NATIONAL RADIOLOGY REPORT TEMPLATES
The templates that comprise the National Radiologyare interconnected as in Figure X-n:
TID xxxx1National Radiology Report
The National Radiology Report template is used for general diagnostic imaging interpretation reports with country-specific extensions that cover national documentation requirements. It contains the mandatory sections “Examination” and “Medical Content”. These sections and other section headings selected from.CID 7001 may appear only once in the template.
TID xxxx1
NATIONAL RADIOLOGY REPORT
Type: Non-Extensible
1 / CONTAINER / BCID(7000) Diagnostic Imaging Report Document Titles / 1 / M / Root node
2 / HAS CONCEPT MOD / CODE / EV (121058,DCM,”Procedure reported”) / 1-n / U
3 / HAS CONCEPT MOD / INCLUDE / DTID(1204) Language of Content Item and Descendants / 1 / M
4 / HAS CONCEPT MOD / INCLUDE / DTID (1210) Equivalent Meaning of Concept Name / 1-n / U
5 / HAS OBS CONTEXT / INCLUDE / DTID(1001) Observation Context / 1 / M / Information on at least one of the following person observers is mandatory:
1) “Performing Physican”
2) “Performing Technologist”.
((For those person observers, requirement types as specified in TID 1003 apply. That means that “Person Observer Name” is the only mandatory attribute.[hk1]the respective roles all person observer identifying attributes of TID 1003 are mandatory)
6 / CONTAINS / INCLUDE / DTID(xxxx2) Examination / 1 / M
7 / CONTAINS / INCLUDE / DTID(xxxx3) Medical Content / 1 / M
8 / CONTAINS / INCLUDE / DTID(xxxx5) NationalGerman Extensions / 1 / MC / Required if specificfor«nationalGermanRadiology Reportrequirements» for the documentation of procedures using ionizing radiation exist
9 / CONTAINS / CONTAINER / BCID(7001) Diagnostic Imaging Report Headings / 1-n / U / Each heading may appear only once in the template
10 / CONTAINS / INCLUDE / DTID(xxxx4) Radiology Report Section Content / 1 / U
No content items other than those defined in Observation Context TID 1001 may be the target of a HAS OBS CONTEXT relationship when TID xxxx1is invoked.
TID xxxx2Examination
Contains information related to the examination.
TID xxxx2
EXAMINATION
Type: Non-Extensible[HK2]
NL / Rel with Parent / VT / Concept Name / VM / Req Type / Condition / Value Set Constraint1 / CONTAINER / EV (121064, DCM, “Current Procedure Descriptions[HK3]”) / 1 / M
2 / CONTAINS / TEXT / EV (123014, DCM, “Target Region“) / 1 / MC / XOR with Row 4
3 / CONTAINS / CODE / EV (123014, DCM, “Target Region“) / 1 / MC / XOR with Row 3 / CID4028, CID4030, CID4031
4 / CONTAINS / TEXT / EV (121065, DCM, “Procedure Description[HK4]”) / 1 / M
5 / CONTAINS / DATE / EV (111060, DCM, ”Study Date”) / 1 / M / Defaults to Study Date (0020,0020) of
General Study Module
6 / CONTAINS / TIME / EV (111061, DCM, ”Study Time”) / 1 / U / Defaults to Study Time (0020,0030) of
General Study Module
7 / CONTAINS / UIDREF / EV (121018, DCM, “Procedure Study Instance UID[HK5]”) / 1 / U / Defaults to Study Instance
UID (0020,000D) of
General Study Module
8 / CONTAINS / COMPOSITE / 1-n / U / Referenced Radiation Dose Reports
Content Item Descriptions
Row 8 / Concept Name is the Root Concept Name (title) of the Radiation Dose StructuredReport composite object instance.TID xxxx3Medical Content
Contains the medical content of the report that comprises relevant medical history data, information on the current request (i.e. clinical question that is expected to be answered by the requested procedure) and impressions on the current imaging procedure that has been performed.
TID xxxx3
MEDICAL CONTENT
Type: Non-ExtensibleOrder[hk6]: Non-Significant
NL / Rel with Parent / VT / Concept Name / VM / Req Type / Condition / Value Set Constraint1 / CONTAINS / CONTAINER[HK7] / EV (121060, DCM, “History”) / 1 / M
2 / CONTAINS / INCLUDE / DTID(xxxx4) Radiology Report Section Content / 1 / M
3 / CONTAINS / CONTAINER / EV (121062, DCM, “Request”) / 1 / M
4 / CONTAINS / INCLUDE / DTID(xxxx4) Radiology Report Section Content / 1 / M
5 / CONTAINS / CONTAINER / EV (121073, DCM, “Impression”) / 1 / M
6 / CONTAINS / INCLUDE / DTID(xxxx4) Radiology Report Section Content / 1 / M
TID xxxx4Radiology Report Section Content
SContains information for section structure and contentsused in the context of the used in the context of the TID xxxx1 template[k8]
TID xxxx4
RADIOLOGY REPORT SECTION CONTENT
Type: Non-Extensible
1 / HAS OBS CONTEXT / INCLUDE / DTID(1001) Observation Context / 1 / U
2 / CONTAINS / CODE / BCID(7002) Diagnostic Imaging Report Elements / 1-n / U
3 / INFERRED FROM / INCLUDE / DTID(2001)Basic Diagnostic Imaging Report Observations / 1-n / U
4 / CONTAINS / TEXT / BCID(7002) Diagnostic Imaging Report Elements / 1-n / U
5 / INFERRED FROM / INCLUDE / DTID(2001)Basic Diagnostic Imaging Report Observations / 1-n / U
6 / CONTAINS / INCLUDE / DTID(2001)Basic Diagnostic Imaging Report Observations / 1-n / U
No content items other than those defined in Observation Context TID 1001 may be the target of a HAS OBS CONTEXT relationship when TID xxxx4xx006 is invoked.
TID xxxx5National Extensions
Country-specific extensions that cover national documentation requirements.
TID xxxx5
NATIONAL EXTENSIONS
Type: Extensible
NL / Rel with Parent / VT / Concept Name / VM / Req Type / Condition / Value Set Constraint1 / CONTAINS / INCLUDE / DTID(xxxx6) German Extension / 1 / MC / Required for German reports on procedures using ionizing radiation
TID xxxx65German Extension
Contains information related to special legislative regulations in Germany.
TID xxxx65
GERMAN EXTENSION
Type: Extensible
NL / Rel with Parent / VT / Concept Name / VM / Req Type / Condition / Value Set Constraint1 / CONTAINER / EV (x994, DCM, “German Extension”) / 1 / M
12 / CONTAINS / INCLUDE / DTID(xxxx76) Information concerning the German X-Ray and Radiation Control Regulation / 1 / M
TID xxxx76Information concerning the German X-Ray and Radiation Control Regulation
Contains information related to the German X-Ray and Radiation Control Regulation.
TID xxxx76
INFORMATION CONCERNING THE GERMAN X-RAY AND RADIATION CONTROL REGULATION
Type: Non-Extensible
NL / Rel with Parent / VT / Concept Name / VM / Req Type / Condition / Value Set Constraint1 / CONTAINS / CONTAINER / EV (121066, DCM, “Prior Procedure Descriptions”) / 1 / M
2 / CONTAINS / TEXT / EV (121065, DCM, “Procedure Description”)[HK9] / 1 / M
3 / CONTAINS / CODE / EV (111532, DCM, “Pregnancy Status”) / 1 / MC / Only for child-bearing woman / DCID (6096)
Pregnancy Status
4 / CONTAINS / TEXT / EV (121109, DCM, “Indications for Procedure[HK10]”) / 1 / M
5 / CONTAINS / PNAME / EV (x1000, DCM, “Physician Responsible for Indication”) / 1 / M
6 / CONTAINS / TEXT / EV (x1001, DCM, “Radiation Exposure“) / 1 / MC / Required for proceduresthat are subject to the German X-Ray Regulation[hk11]
7 / CONTAINS / TEXT / EV (x1002, DCM, “Radioactive Substance Administered”) / 1 / MC / Required for proceduresthat are subject to the German Radiation Control Regulation[hk12]
Content Item Descriptions
Row 6 / By German law only a textual, human readable description of the radiation exposure is required. Detailed specification of exposure is out of the scope of this context. Such information may be given in a separate object as described in Supp 94,Radiation Dose Reportor Supp 127, CT Radiation Dose Reporting (Dose SR).Item #24: Add the following Definitions to Annex D
DICOM Code Definitions (Coding Scheme Designator “DCM” Coding Scheme Version “01”)
Code Value/ Code Meaning / Definition
x994 / German Extension / German extension of the National Radiology Report
x1000 / Physician Responsible for Indication[k13] / Physician who was responsible for indication
x1001 / Radiation Exposure[k14] / Estimated radiation dose to the patient resulting from the procedure beingreported.
x1002 / Radioactive Substance Administered[k15] / Substance type, amount and route of radioactive substance administered.
Item #35: Extend the Context ID 7001
Context ID 7001
Diagnostic Imaging Report Headings
Type: Extensible Version: 20070712
Coding Scheme Designator(0008,0102) / Code Value
(0008,0100) / Code Meaning
(0008,0104)
DCM / 121060 / History
DCM / 121062 / Request
DCM / 121064 / Current Procedure Descriptions
DCM / 121066 / Prior Procedure Descriptions
DCM / 121068 / Previous Findings
DCM / 121070 / Findings
DCM / 121072 / Impressions
DCM / 121074 / Recommendations
DCM / 121076 / Conclusions
DCM / 121078 / Addendum
DCM / 121109 / Indications for Procedure
DCM / 121110 / Patient Presentation
DCM / 121113 / Complications
DCM / 121111 / Summary
DCM / 121180 / Key Images
DCM / X994 / German Extension
Item #47: Add a new Annex
Annex XGerman Translations of Selected Codes used in the DCMR (Normative)
Coding Scheme Designator / Coding Scheme Version / Code Value / Code MeaningEnglish Language / Code Meaning
German Language
LN / 11528-7 / Radiology Report / Radiologischer Befundbericht
DCM / 121066 / Prior Procedure Descriptions / Frühere Untersuchungen
DCM / 111532 / Pregnancy Status / Schwangerschaft
DCM / 121109 / Indications for Procedure / Rechtfertigende Indikation
DCM / 123014 / Target Region / Körperregion
DCM / 121064 / Current Procedure Descriptions / Untersuchungstechnik
DCM / 111060 / Study Date / Datum der Untersuchung
DCM / 111061 / Study Time / Zeitpunkt der Untersuchung
DCM / 110180 / Study Instance UID / Study Instance UID
DCM / 121060 / History / Klinische Angaben
DCM / 121062 / Request / Fragestellung
DCM / 121071 / Finding / Beschreibung
DCM / 121073 / Impression / Wertung
DCM / 121075 / Recommendation / Empfehlung
DCM / X994 / German Extension / Deutsche Erweiterung
DCM / x1000 / Physician Responsible for Indication / Indikationsstellender Arzt
DCM / x1001 / Radiation Exposure / Strahlenexposition
DCM / x1002 / Radioactive Substance Administered / Verabreichter radioaktiver Stoff
[hk1]Clarification on person observer mandatory data added.
[HK2]Allow extensions for procedure details in this section
[HK3]Replaced Examination with code available in CID 7001. How is that related to Procedure Code in TID1005 “Procedure Context”
[HK4]Aligned with CID 7002 Diagnostic Imaging Report Elements
[HK5]Aligned with TID 1005 Procedure Context -> since this study instance UID is already included as optional in TID 1005, do we need to repeat it here?
[hk6]WG6 question related to DICOM CP-463 answered -> order of sections is not significant
[HK7]Changed Nesting (aligned with nesting level of other document sections)
[k8]Structure and contents are identical to TID 2000 section content
[HK9]Aligned with TID 2000 use of sections and report elements
[HK10]Used as new report element code
[hk11]Changed to address both regulations for hybrid imaging procedures (e.g. PET/CT)
[hk12]Changed to address both regulations for hybrid imaging procedures (e.g. PET/CT)
[k13]Add to CID 7452?
[k14]113736 Exposure e.g. used in TID 10003
[k15]Context Group?