Addendum If the header includes a relatedDocument element with typeCode APND, the component/structuredBody contain exactly one [1..1] Addendum SHALL Section. DIR Clinical Statements A Diagnostic Imaging Report may contain CDA entries in any of its sections that represent, in coded form findings, image references, annotation, and numeric measurements. See PS 3.20 “Transformation of DICOM to and from HL7 Standards” for descriptions of transformations of observations from DICOM Structured Reporting instances. For this document template, Spatial Coordinates region of interest (SCOORD) for linear, area, and volume measurements are not encoded in the CDA document. If it is desired to show images with such graphical annotations, the annotations should be encoded in DICOM Softcopy Presentation State objects that reference the image. Report applications that display referenced images and annotation may retrieve a rendered image using a WADO reference in accordance with PS3.18, including the image and Presentation State, or other DICOM retrieval and rendering methods. This approach avoids the risks of errors in registering a CDA region of interest annotation with DICOM images. Interventional Radiology Report (reserved) Similar to diagnostic; includes consents, sedation, blood loss? Use Procedure Description rather than Current Imaging Procedure Description Anatomic Pathology Report (reserved) Kussaibi, et al. “HL7 CDA Implementation Guide for Structured Anatomic Pathology Reports Methodology and Tools” doi:10.3233/978-1-60750-588-4-289 CLINICAL INFORMATION Reason for AP procedure Clinical information provided by the ordering History of present illness physician: reason for anatomic pathology procedure, Active Problems active problems (preoperative and/or postoperative Specimen clinical information entry diagnosis, lab data), collection procedure(s) and Specimen Information Organizer specimen description(s) for all delivered specimen(s) o Collection procedure reported separately. o Specimen(s) type o Specimen location INTRAOPERATIVE EXAMINATION (conditional) Intraoperative entry Intraoperative diagnoses +/- images for all delivered Specimen Information Organizer specimen( s) reported separately. o Diagnostic observation o Link(s) to images
Addendum If the header includes a relatedDocument element with typeCode APND, the component/structuredBody SHALL contain exactly one [1..1] Addendum Section. DIR Clinical Statements A Diagnostic Imaging Report may contain CDA entries in any of its sections that represent, in coded form findings, image references, annotation, and numeric measurements. See PS 3.20 “Transformation of DICOM to and from HL7 Standards” for descriptions of transformations of observations from DICOM Structured Reporting instances. For this document template, Spatial Coordinates region of interest (SCOORD) for linear, area, and volume measurements are not encoded in the CDA document. If it is desired to show images with such graphical annotations, the annotations should be encoded in DICOM Softcopy Presentation State objects that reference the image. Report applications that display referenced images and annotation may retrieve a rendered image using a WADO reference in accordance with PS3.18, including the image and Presentation State, or other DICOM retrieval and rendering methods. This approach avoids the risks of errors in registering a CDA region of interest annotation with DICOM images. Interventional Radiology Report (reserved) Similar to diagnostic; includes consents, sedation, blood loss? Use Procedure Description rather than Current Imaging Procedure Description Anatomic Pathology Report (reserved) Kussaibi, et al. “HL7 CDA Implementation Guide for Structured Anatomic Pathology Reports Methodology and Tools” doi:10.3233/978-1-60750-588-4-289 CLINICAL INFORMATION Clinical information provided by the ordering physician: reason for anatomic pathology procedure, active problems (preoperative and/or postoperative diagnosis, lab data), collection procedure(s) and specimen description(s) for all delivered specimen(s) reported separately. Reason for AP procedure History of present illness Active Problems Specimen clinical information entry Specimen Information Organizer o Collection procedure o Specimen(s) type o Specimen location INTRAOPERATIVE EXAMINATION (conditional) Intraoperative diagnoses +/- images for all delivered specimen( s) reported separately. Intraoperative entry Specimen Information Organizer o Diagnostic observation o Link(s) to images
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