Template 2.16.840.1.113883.2.51.10.1.9.1

Template XeH Imaging Report

Id 2.16.840.1.113883.2.51.10.1.9.1 Effective Date 2021‑06‑22 14:23:06

Status Cancelled Version Label

Name ImagingReport Display Name XeH Imaging Report

Description

This CDA Imaging Report document template defines the report content and technical constraints for top level elements, attributes, sections, and entries to be used in imaging report instances. This template may apply to screening, diagnostic, or therapeutic radiology, cardiology, or other imaging reports. The body of an Imaging Report may contain five main imaging report sections:
• Clinical information (optionally);
• Current imaging procedure description;
• Comparison studies (optionally);
• Findings (optionally);
• Impression;
• plus potentially an Addendum(s) The report templates sponsored by the RSNA Radiology Reporting Initiative (http://www.radreport.org) adhere to this general section outline. The section and subsection structure of this template is also identified by LOINC panel code 87416-4.

Context Parent nodes of template element with id 2.16.840.1.113883.2.51.10.1.9.1

Classification CDA Document Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 0 templates, Uses 7 templates

Uses	as	Name	Version
2.16.840.1.113883.3.1937.99.61.67.10.18	Include	XeH Clinical Document	DYNAMIC
1.2.840.10008.9.2	Containment	Clinical Information (DICOM-20150324)	DYNAMIC
1.2.840.10008.9.3	Containment	Imaging Procedure Description (DICOM-20150324)	DYNAMIC
1.2.840.10008.9.4	Containment	Comparison Study (DICOM-20150324)	DYNAMIC
2.16.840.1.113883.10.20.6.1.2	Containment	Findings (DICOM-20150324)	DYNAMIC
1.2.840.10008.9.5	Containment	Impression (DICOM-20150324)	DYNAMIC
1.2.840.10008.9.6	Containment	Addendum (DICOM-20150324)	DYNAMIC

Item DT Card Conf Description Label

hl7:ClinicalDocument (Imaort)

hl7:templateId II 1 … 1 M (Imaort)

@root uid 1 … 1 F 2.16.840.1.113883.2.51.10.1.9.1

hl7:code CD (extensible) 1 … 1 R (Imaort)

Included 1 … 1 R from 2.16.840.1.113883.3.1937.99.61.67.10.18 XeH Clinical Document (DYNAMIC)

hl7:ClinicalDocument 1 … 1 R (Imaort)

@classCode cs 0 … 1 F DOCCLIN

@moodCode cs 0 … 1 F EVN

hl7:realmCode

0 … 1

This attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question.

This element should not be used for identifying the originating country.

(Imaort)

hl7:typeId II 1 … 1 R (Imaort)

@root uid 1 … 1 F 2.16.840.1.113883.1.3

@extension st 1 … 1 F POCD_HD000040

hl7:templateId II 1 … 1 R (Imaort)

@root uid 1 … 1 F 2.16.840.1.113883.3.1937.99.61.67.10.18

hl7:id II 1 … 1 R (Imaort)

hl7:code CE 1 … 1 R The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note).
The value set is drawn from LOINC. (Imaort)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)

hl7:title ST 1 … 1 M Narrative title of the document, usually shown to the user. (Imaort)

hl7:effectiveTime

1 … 1

The date/time of document creation.

Where the CDA document is transformed into another format, the ClinicalDocument.effectiveTime of the original document is preserved.

(Imaort)

hl7:confidentialityCode CE 1 … 1 R (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)

hl7:languageCode CS (preferred) 1 … 1 R (Imaort)

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)

hl7:setId

1 … 1

Common identifier to all revisions of the document

(Imaort)

hl7:versionNumber INT 1 … 1 R (Imaort)

Included

1 … *

from 2.16.840.1.113883.3.1937.99.61.67.10.1 XeH CDA recordTarget (DYNAMIC)

The recordTarget represents the medical record that this document belongs to.

A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.

hl7:recordTarget 1 … * R (Imaort)

@typeCode cs 0 … 1 F RCT

@contextControlCode cs 0 … 1 F OP

Example <recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
<id root="1.2.3.999" extension="__example only__"/> <addr>
<streetAddressLine>HSE M CASSAR STR</streetAddressLine> <city>ISLA</city> <country>MT</country> </addr> <telecom use="HP" value="tel:+356124567891"/> <telecom use="WP" value="mailto:elif@foo.too.mt"/> <patient>
<name>
<family>BORG</family> <given>TANIA</given> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19430130"/> 

</patient> </patientRole></recordTarget>

hl7:patientRole 1 … 1 M (Imaort)

@classCode cs 0 … 1 F PAT

hl7:id II 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) (Imaort)

hl7:addr AD.IPS 1 … * R The patient address. (Imaort)

Constraint When used for cross-border exchange the country address part has to be provided.

Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)

@nullFlavor cs 0 … 1 F NI

Constraint SHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line (Imaort)

Schematron assert role error

test hl7:streetAddressLine and (hl7:city or hl7:postalCode)

Message If the address line is included either the city or the zip code has to be provided

hl7:city ADXP 0 … 1 C Subject's or Organization's City (Imaort)

hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code (Imaort)

hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province (Imaort)

hl7:country ADXP 0 … 1 C Subject's Country. (Imaort)

Constraint The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

hl7:telecom TEL 1 … * R Patient’s telecom information : e.g. telephone number, e-mail address. (Imaort)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@nullFlavor cs 0 … 1 F NI

Constraint If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

Example <telecom use="HP" value="tel:+356124567891"/>

Example <telecom use="WP" value="mailto:elif@foo.too.mt"/>

Example <telecom nullFlavor="NI"/>

hl7:patient 1 … 1 M (Imaort)

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

Example

Japanese example (Person Name)

<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>

hl7:name PN 1 … * M Patient Name (Imaort)

Constraint The Alphabetic representation of the name SHALL be always provided

hl7:family 1 … * R Patient's Family Name/Surname (Imaort)

hl7:given 1 … * R Patient's Given Name (Imaort)

hl7:administrativeGenderCode CE.IPS 1 … 1 R Patient's Gender (Imaort)

@nullFlavor cs 0 … 1 F UNK

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)

Example <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
<translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>

hl7:birthTime TS 1 … 1 R Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. (Imaort)

hl7:guardian

0 … *

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

(Imaort)

@classCode cs 1 … 1 F GUARD

Example <guardian classCode="GUARD">
<code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/> <addr nullFlavor="NI"/> <telecom use="MC" value="tel:+33-12345678"/> <guardianPerson>
<name>
<family>Curie</family> <given>Marie</given> </name> </guardianPerson></guardian>

hl7:code CD.IPS 0 … 1 R The relationship between the patient and the guardian or other contact may be recorded in the element. (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)

hl7:addr AD.IPS 1 … * R (Imaort)

Constraint If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.

Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)

@nullFlavor cs 0 … 1 F NI

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line (Imaort)

Schematron assert role error

test hl7:streetAddressLine and (hl7:city or hl7:postalCode)

Message If the address line is included either the city or the zip code has to be provided

hl7:city ADXP 0 … 1 C Subject's or Organization's City (Imaort)

hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code (Imaort)

hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province (Imaort)

hl7:country ADXP 0 … 1 C Subject's Country. (Imaort)

hl7:telecom TEL 1 … * R Guardian’s telecom information: e.g. telephone number; e-mail address. (Imaort)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@nullFlavor cs 0 … 1 F NI

hl7:guardianPerson 1 … 1 R (Imaort)

hl7:name PN 1 … * R Patient Guardian's Name (Imaort)

hl7:family ENXP 1 … * R Patient Guardian's Family Name/Surname (Imaort)

hl7:given ENXP 1 … * R Patient Guardian's Given Name (Imaort)

hl7:languageCommunication 0 … * R (Imaort)

hl7:languageCode CS 1 … 1 R Patient’s language (Imaort)

Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)

Example

British English

Example

Amurdak (Australia)

Schematron assert role error

test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')

Message The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code)

Included 1 … * R from 2.16.840.1.113883.3.1937.99.61.67.10.2 XeH CDA author (DYNAMIC)
Represents the humans and/or machines that authored the document.
The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute.
If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Physician Progress Note" and the value of Author.functionCode is "rounding physician"), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

hl7:author 1 … * R (Imaort)

@typeCode cs 0 … 1 F AUT

@contextControlCode cs 0 … 1 F OP

Example <author>
<time value="201212290600+0100"/> <assignedAuthor>
<id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:+39-051-34343434"/> <assignedPerson>
<name>
<given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor> <representedOrganization>

</representedOrganization></author>

hl7:functionCode CE.IPS 0 … 1 R (Imaort)

hl7:time TS.IPS.TZ 1 … 1 R The author/time element represents the start time of the author’s participation in the creation of the clinical document. (Imaort)

Example <time value="201212290600+0100"/>

hl7:assignedAuthor 1 … 1 R (Imaort)

@classCode cs 0 … 1 F ASSIGNED

hl7:id II 1 … * R Author Identifier(s) (Imaort)

@nullFlavor cs 0 … 1

hl7:code CE.IPS (extensible) 0 … 1 R A code, which identifies the profession/competence/specialty of the author when it is a person. (Imaort)

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)

Example <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>

hl7:addr AD.IPS 1 … * R (Imaort)

Example <addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country></addr>

hl7:telecom TEL.IPS 1 … * R (Imaort)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@value st 0 … 1

Example <telecom use="WP" value="tel:+39-051-34343434"/>

Example <telecom nullFlavor="NI"/>

Choice

1 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

hl7:assignedPerson 0 … 1 C (Imaort)

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

hl7:name PN 1 … * R Name of the person (e.g. the Healthcare Professional) authoring this document (Imaort)

Example <name>
<given>John</given> <family>Español Smith</family></name>

hl7:family 1 … * R (Imaort)

hl7:given 1 … * R (Imaort)

hl7:assignedAuthoringDevice 0 … 1 C Contains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) (Imaort)

Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
<softwareName displayName="Turriano"/></assignedAuthoringDevice>

hl7:representedOrganization 0 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (Imaort)

Included 0 … 1 from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)

hl7:dataEnterer 0 … 1 (Imaort)

@typeCode 0 … 1 F ENT

@contextControlCode 0 … 1 F OP

hl7:time TS 0 … 1 (Imaort)

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

Included 0 … * from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)

hl7:informant 0 … * (Imaort)

@typeCode 0 … 1 F INF

@contextControlCode 0 … 1 F OP

Choice

1 … 1

Elements to choose from:

hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)

hl7:assignedEntity Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

hl7:relatedEntity Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) (Imaort)

Included 1 … 1 R from 2.16.840.1.113883.3.1937.99.61.67.10.5 XeH CDA custodian (DYNAMIC)
Represents the organization that is in charge of maintaining the document.

The custodian is the steward that is entrusted with the care of the document.

hl7:custodian 1 … 1 R (Imaort)

@typeCode cs 0 … 1 F CST

Example <custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">

</representedCustodianOrganization> </assignedCustodian></custodian>

hl7:assignedCustodian 1 … 1 R (Imaort)

@classCode cs 0 … 1 F ASSIGNED

hl7:representedCustodianOrganization 1 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (Imaort)

@classCode cs 0 … 1 F ORG

@determinerCode cs 0 … 1 F INSTANCE

Included

0 … *

from 2.16.840.1.113883.10.12.105 CDA informationRecipient (DYNAMIC)

Represents a recipient who should receive a copy of the document.

hl7:informationRecipient 0 … * (Imaort)

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)

hl7:intendedRecipient 1 … 1 (Imaort)

@classCode cs 1 … 1 R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)

hl7:id II 0 … * R (Imaort)

hl7:addr AD 0 … * (Imaort)

hl7:telecom TEL 0 … * (Imaort)

hl7:informationRecipient 0 … 1 Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) (Imaort)

hl7:receivedOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (Imaort)

Included 0 … 1 R from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC)

hl7:legalAuthenticator 0 … 1 R (Imaort)

@typeCode 0 … 1 F LA

@contextControlCode 0 … 1 F OP

hl7:time TS 1 … 1 R (Imaort)

hl7:signatureCode CS 1 … 1 R (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

Included 0 … * R from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)

hl7:authenticator 0 … * R (Imaort)

@typeCode 0 … 1 F AUTHEN

hl7:time TS 1 … 1 R (Imaort)

hl7:signatureCode CS 1 … 1 R (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

Included 0 … * from 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)

hl7:participant 0 … * (Imaort)

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)

@contextControlCode 0 … 1 F OP

hl7:functionCode CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)

hl7:time IVL_TS 0 … 1 (Imaort)

hl7:associatedEntity 1 … 1 (Imaort)

@classCode cs 1 … 1 R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)

hl7:id II 0 … * (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

shall be drawn from concept domain "RoleCode"

hl7:addr AD 0 … * (Imaort)

hl7:telecom TEL 0 … * (Imaort)

hl7:associatedPerson 0 … 1 Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) (Imaort)

hl7:scopingOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (Imaort)

Included 0 … * from 2.16.840.1.113883.10.12.109 CDA inFulfillmentOf (DYNAMIC)

hl7:inFulfillmentOf 0 … * (Imaort)

@typeCode 0 … 1 F FLFS

hl7:order 1 … 1 (Imaort)

@classCode 0 … 1 F ACT

@moodCode 1 … 1 F RQO

hl7:id II 1 … * R (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

shall be drawn from concept domain "ActCode"

hl7:priorityCode CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)

Included 0 … * from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC)

hl7:documentationOf 0 … * (Imaort)

@typeCode 1 … 1 F DOC

hl7:serviceEvent 1 … 1 (Imaort)

@classCode 1 … 1 F ACT

@moodCode 1 … 1 F EVN

hl7:id II 0 … * (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

shall be drawn from concept domain "ActCode"

hl7:effectiveTime IVL_TS 0 … 1 (Imaort)

hl7:performer 0 … * (Imaort)

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)

hl7:functionCode CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)

hl7:time IVL_TS 0 … 1 (Imaort)

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

Included 0 … 2 R from 2.16.840.1.113883.10.12.111 CDA relatedDocument (DYNAMIC)
A reference to a ParentDocument representing the source of a document revision, addenda, or transformation.

Constraint

hl7:relatedDocument 0 … 2 R (Imaort)

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)

hl7:parentDocument 1 … 1 (Imaort)

@classCode 0 … 1 F DOCCLIN

@moodCode 0 … 1 F EVN

hl7:id II 1 … * R (Imaort)

hl7:code CD 0 … 1 (Imaort)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)

hl7:text ED 0 … 1 (Imaort)

hl7:setId II 0 … 1 (Imaort)

hl7:versionNumber INT 0 … 1 (Imaort)

Included 0 … * from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)

hl7:authorization 0 … * (Imaort)

@typeCode 0 … 1 F AUTH

hl7:consent 1 … 1 (Imaort)

@classCode 0 … 1 F CONS

@moodCode 0 … 1 F EVN

hl7:id II 0 … * (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

shall be drawn from concept domain "ActCode"

hl7:statusCode CS 1 … 1 R (Imaort)

@code CONF 0 … 1 F completed

Included 0 … 1 from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
A reference to the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.

hl7:componentOf 0 … 1 (Imaort)

@typeCode 0 … 1 F COMP

hl7:encompassingEncounter 1 … 1 (Imaort)

@classCode 0 … 1 F ENC

@moodCode 0 … 1 F EVN

hl7:id II 0 … * (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)

hl7:effectiveTime IVL_TS 1 … 1 R (Imaort)

hl7:dischargeDispositionCode CE 0 … 1 (Imaort)

CONF

shall be drawn from concept domain "EncounterDischargeDisposition"

hl7:responsibleParty 0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

@typeCode 0 … 1 F RESP

hl7:encounterParticipant 0 … * (Imaort)

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)

hl7:time IVL_TS 0 … 1 (Imaort)

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Imaort)

hl7:location 0 … 1 (Imaort)

@typeCode 0 … 1 F LOC

hl7:healthCareFacility 1 … 1 (Imaort)

@classCode 0 … 1 F SDLOC

hl7:id II 0 … * (Imaort)

hl7:code CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)

hl7:location 0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) (Imaort)

hl7:serviceProviderOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (Imaort)

Included 1 … 1 R from 2.16.840.1.113883.10.12.112 CDA component (DYNAMIC)

hl7:component 1 … 1 R (Imaort)

@typeCode 0 … 1 F COMP

@contextConductionInd bl 0 … 1 F true

Choice

1 … 1

Elements to choose from:

hl7:nonXMLBody included from template 2.16.840.1.113883.10.12.203 CDA NonXMLBody (DYNAMIC)
hl7:structuredBody included from template 2.16.840.1.113883.10.12.202 CDA StructuredBody (DYNAMIC)

Included from 2.16.840.1.113883.10.12.203 CDA NonXMLBody (DYNAMIC)

hl7:nonXMLBody (Imaort)

@classCode 0 … 1 F DOCBODY

@moodCode 0 … 1 F EVN

hl7:text ED 1 … 1 (Imaort)

hl7:confidentialityCode CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)

hl7:languageCode CS 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)

Included from 2.16.840.1.113883.10.12.202 CDA StructuredBody (DYNAMIC)

hl7:structuredBody (Imaort)

@classCode 0 … 1 F DOCBODY

@moodCode 0 … 1 F EVN

hl7:confidentialityCode CE 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)

hl7:languageCode CS 0 … 1 (Imaort)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)

hl7:component 1 … * Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC) (Imaort)

@typeCode 0 … 1 F COMP

@contextConductionInd bl 0 … 1 F true

hl7:component 1 … 1 R (Imaort)

hl7:structuredBody 1 … 1 R (Imaort)

hl7:component 0 … 1 (Imaort)

hl7:section Contains 1.2.840.10008.9.2 Clinical Information (DYNAMIC) (Imaort)

hl7:component 1 … 1 R (Imaort)

hl7:section Contains 1.2.840.10008.9.3 Imaging Procedure Description (DYNAMIC) (Imaort)

hl7:component 0 … 1 (Imaort)

hl7:section Contains 1.2.840.10008.9.4 Comparison Study (DYNAMIC) (Imaort)

hl7:component 1 … 1 R (Imaort)

hl7:section Contains 2.16.840.1.113883.10.20.6.1.2 Findings (DYNAMIC) (Imaort)

hl7:component 1 … 1 R (Imaort)

hl7:section Contains 1.2.840.10008.9.5 Impression (DYNAMIC) (Imaort)

hl7:component 0 … * C (Imaort)

Constraint If the header includes a relatedDocument element with typeCode RPLC, and the replaced document had a legalAuthenticator element (i.e., was signed), the component/structuredBody SHALL contain at least one 9.7 Addendum.

hl7:section Contains 1.2.840.10008.9.6 Addendum (DYNAMIC) (Imaort)

Template XeH Imaging Report