Diagnostic Imaging Report - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
POII_RM040000UK01  
DIReport

This is the message used to convey a Diagnostic Imaging Report dataset from the Service Provider to the Requestor.

The dataset is described in full in the document: Diagnostic Imaging - DI Reports to Primary Care and PSIS (P2R1): NPFIT-FNT-TO-DPM-0126.01

Used by:
[1..1] classCode (CS {CNE:INFRM} ){ Fixed="INFRM " }

A code indicating that the DIReport message is for information purposes

  • Fixed value: "INFRM"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

UUID identifying this instance of this message. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance it is the globally unique identifier for this instance of the DIReport message

(W5 Ref: Section 1.1)

[1..1] code (CD {CNE:SnomedCT} )

A code from the SnomedCT UK subset that describes this message as being a 'Diagnostic Imaging Report'.

  •  Fixed Value: "163581000000104"
  •  Datatype Flavour:  Coded Plain

 (W5 Ref: Section 1.3)

[1..1] effectiveTime (TS)

This is the date and time stamp at which point the DIReport communication was initiated by the fulfiller system. This is not the message timestamp, which is provided in the wrapper.

Format: yyyymmddhhmmss

(W5 Ref: Section 1.2)

[1..1] recordTarget

A link between the DIReport focalAct and the details of the patient to whom it relates.

[1..1] typeCode (CS {CNE:RCT} ){ Fixed="RCT " }

A code indicating that the patient's records will hold the information relating to this DIReport

  • Fixed value: "RCT"
[1..1] patient (Patient)

A link to the details of the patient

[0..1] author

A link between the DIReport focalAct and the details of it's author who may, depending on message trigger point, be either a real person or a fulfiller system.

Note: this is the author of the MESSAGE, not necessarily the report(s) it contains. Although this author does conduct down to the pertinent/component acts it will be replaced by the author details added there (author1).

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

A code indicating that this is the author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] role (AuthorChoice)

A link to the details of the author of the message. This links to a choice of either a named person or a named device (e.g. the RIS)

(W5 Ref: Section 1.4)

[1..1] primaryInformationRecipient

A link between the DIReport focalAct and the details of the person to whom it is sent with the expectation that they act on it's contents.

[1..1] typeCode (CS {CNE:PRCP} ){ Fixed="PRCP " }

A code indicating that this is the Primary Recipient of the message

  • Fixed value: "PRCP"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPFIT CMET:  R_AgentNPFITPersonSDS used to identify the person who is the intended Primary Recipient of this message.

(W5 Ref: Section 3.1)

[1..1] tracker1

A link between the DIReport focalAct and the details of PSIS, which is always a recipient of the contents of the message. 

(W5 Ref: Section 4.2)

[1..1] typeCode (CS {CNE:TRC} ){ Fixed="TRC " }

Indicates that the message is to be 'copied to' the agent identified.

  • Fixed value : "TRC"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent      [CMET: UKCT_MT120501UK03]

A link to the NPFIT CMET:  R_AgentNPFITOrganizationSDS used to identify PSIS as the recipient of a copy of this message.

(W5 Ref: Section 4.2)

[0..*] tracker2

A link between the DIReport focalAct and the details of any other pre-named intended recipients of the contents of the message. 

(W5 Ref: Section 4.1)

[1..1] typeCode (CS {CNE:TRC} ){ Fixed="TRC " }

Indicates that the message is to be 'copied to' the agent identified.

  • Fixed value : "TRC"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPFIT CMET:  R_AgentNPFITPersonSDS used to identify the person who is the intended recipient of a copy of this message.

(W5 Ref: Section 4.1)

[1..1] pertinentInformation1

A link between the DIReport message focal act and the details of the DI Report(s) that it contains.

[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates that this is pertinent information.

  • Fixed value: "PERT"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.pertinentinformation"
[1..1] pertinentReportGrouper (ReportGrouper)

A link to the details of the ReportGrouper

[1..*] pertinentInformation2

A link between the FocalAct and the details of the Care Record Element (CRE) Categories of the Acts contained within this message.

[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates that this is pertinent information.

  • Fixed value: "PERT"
[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.pertinentinformation1"
[1..1] pertinentCRECategory (CRECategory)

A link to the details described by the CRECategory.

This information is mandatory.

[1..1] inFulfillmentOf

A link between the DIReport focalAct and the details of the Fulfiller Request which it fulfills.

[1..1] typeCode (CS {CNE:FLFS} ){ Fixed="FLFS " }

Indicates that this is in fulfills a request.

  • Fixed value: "FLFS"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] priorFulfillerRequest (FulfillerRequest)

A link to the details of the Fulfiller Request.

(W5 Ref: Section 5.2)

[0..1] replacementOf

A link between this DIReport focalAct and the details of the previous DIReport focalAct which this is intended to replace.

[1..1] typeCode (CS {CNE:RPLC} ){ Fixed="RPLC " }

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[1..1] priorMessageRef (MessageRef)

A link to the details of the previous message which this one is now replacing.

(W5 Ref: Section 1.5)

Patient

Details about the patient.

(W5 Ref: Section 2.1)

Used by: DIReport
[1..1] classCode (CS {CNE:PAT} ){ Fixed="PAT " }

A code indicating that this is the patient

  • Fixed value: "PAT"
[1..1] id (II)

The NHS number that identifies the patient.

  • The root element identifies the  NHS patient numbering scheme represented by OID 2.16.840.1.113883.2.1.4.1
  • The extension contains the 10 digit NHS number.
AuthorChoice

Details of the author of the message.

Note: Depending on implemetation and local rules, this may be a person or a device.

(W5 Ref: Section 1.4)

Used by: DIReport
[1..1] either : UKCT_MT120701UK02

A link to the NPfIT CMET:  R_AgentNPFITDeviceSDS used to identify the device (Fulfiller System) that triggered the sending of this message.

             ... or ... : UKCT_MT120301UK02

A link to the NPfIT CMET:  R_AgentNPFITPersonSDS used to identify the person who triggered the sending of this message (i.e. became the author).

ReportGrouper

Details about the report(s) contained within this message.

(W5 Ref: Section 6.1)

Used by: DIReport
[1..1] classCode (CS {CNE:ENTRY} ){ Fixed="ENTRY " }

A code to indicate this is an entry.

  • Fixed value: "ENTRY"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..2] id (LIST<II>)

The identifier for the Report Grouper which is in essence the Fulfiller Report. It is in the form of a list. 

This ID consists of 2 parts:

  1. the globally unique number to identify the Fulfiller Report ID (DCE UUID)
  2. the fulfiller system OID + the fulfiller system Fulfiller Report ID.         This is included to allow the viewer to see the 'friendly' identifier but may not necessarily be present.

(W5 Ref: Section 6.1.2)

[1..1] code (CD {CNE:SnomedCT} )

A code from the SnomedCT UK subset that describes this act as a Report Grouper.

  • Fixed Value: "163651000000109"
  • Datatype Flavour: Coded with Qualifier(s)
[1..1] statusCode (CS {CNE:ActStatus} )

A code from the HL7 V3 subset called 'ActStatus' which describes the status of the act, in this case the status of this instance of the Fulfiller Report.

Allowed values are: 

  1. 'Active'  - there are some outstanding Procedures/reports.
  2. 'Completed'  (default value) - this is the final status

(W5 Ref: Section 6.1.4)

[1..1] effectiveTime (TS)

This is the date and time stamp at which the DIReport contents were 'authorised for release' from the Service Provider.

Format: yyyymmddhhmmss

Note:  Depending on system implementation/local rules this could be the time stamp of the transcription (for unverified release) or the verfication (for verified release)

(W5 Ref: Section 6.1.3)

[1..1] priorityCode (CS {CNE:PriorityType} )

A code from the HL7 V3 subset called 'PriorityCode' which describes the priority of the act, in this case the priority (if given) of the DI Report.

Allowed values are:

  1. 'Routine' (default value)
  2. 'Urgent'

(W5 Ref: Section 6.1.5)

[1..1] author

A link between the ReportGrouper and the details of the author of the report(s) it contains.

Note: This author is inherited by the ProcedureReport and SummaryReport segments unless a new author is identified separately at these levels.

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

A code indicating that this is the author of the report

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET R_AgentNPFITPersonSDS used to identify the person who has authored the content of the DI Report.

(W5 Ref: Section 6.1.6)

[0..1] verifier

A link between the ReportGrouper and the details of the person who has verified the report contents. 

Note:

  1. The verifier is the person who reads the transcribed report(s) and agrees/amends the contents taking clinical responsibility for them.
  2. Depending on implementation issues/local practice this may not be used.
  3. This verifier is inherited by the ProcedureReport and SummaryReport segments unless a new verifier is identified separately at these levels.
[1..1] typeCode (CS {CNE:VRF} ){ Fixed="VRF " }

A code indicating that this is the verifier of the contents of the report(s) contained within the message

  • Fixed value: "VRF"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET:  R_AgentNPFITPersonSDS used to identify the person who has verified the content of the report(s) contained within this message.

(W5 Ref: Section 6.1.7)

[1..1] primaryPerformer

A link between the ReportGrouper and the details of the service provider who is responsible for the contents of this DI Report message.

[1..1] typeCode (CS {CNE:PPRF} ){ Fixed="PPRF " }

A code indicating that this is the Primary Performer who is responsible for the contents of the report(s)

  • Fixed value: "PPRF"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120501UK03)

A link to the NPfIT CMET:  R_AgentNPFITOrganizationSDS used to identify the organization clinically responsible for the production and content of the report(s) contained within this message.

Note:   There is an expectation that SDS Org codes will identify at least the DI Service Provider, if not the departments within it.

(W5 Ref: Section 6.1.1)

[0..1] component1

A link between the ReportGrouper and the details of the DI Summary Report which it may contain.

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.component"
[1..1] summaryReportSegment (SummaryReportSegment)

A link to the details of the Summary Report contained within this message.

[1..*] component2

A link between the ReportGrouper and the details of the DI Procedure Report(s) it may contain.

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to put individual DI Procedure Reports into a specific sequence/order within the ReportGrouper act.

This will only be present if there are 2 or more DI Procedure Reports and the Fulfiller System wishes to utilise this function.

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.component"
[1..1] procedureReportSegment (ProcedureReportSegment)

A link to the details of the DI Procedure Report(s) contained within this message.

[1..*] component3

A link between the ReportGrouper and the details of the DI Procedure Instances that are referenced by the DI Procedure Report(s) contained in this message.

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to put individual DI Procedure Instances that have been referenced by the ProcedureReportSegment act into a specific sequence/order within the ReportGrouper act.

This will only be present if there are 2 or more DI Procedure Instances and the Fulfiller System wishes to utilise this function.

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.component"
[1..1] dIProcedure (DIProcedure)

A link to the details of the DI Procedure Instance(s) that have been reported/referenced within this message  

CRECategory

An act used to categorise clinical statement acts contained within the message into Care Record Element categories.

Note:   The CRECategory act can reference multiple ActRef acts to 'group' multiple clinical statements under a single category.

Used by: DIReport
[1..1] classCode (CS {CNE:CATEGORY} ){ Fixed="CATEGORY " }

Indicates that this act is a category act.

  • Fixed value : "CATEGORY"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] code (CD {CWE:CRETypeSnCT} )

Coding system used to categorise the clinical statement messages:

The datatype flavour Coded with Code System is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the CRETypeSnCT vocabulary;
  • The codeSystem attribute will contain the OID value referenced in the CRETypeSnCT vocabulary.

All clinical statements within this message can be categorised by CREType:

  1. Statements with classCode 'OBS' and moodCode 'EVN'  (except CodedDiagnosis) and those statements with classCode 'ENTRY' and moodCode 'EVN' are Investigation Results. These are identified  by the use of the SnCT Concept code '163141000000104'.
  2. Statements with classCode 'OBS' and moodCode 'EVN' and the act name of 'DIProcedure' are Investigations. These are identified using the SnCT Concept code '163081000000108'.
  3. Statements with the classCode 'OBS' and moodCode 'EVN' and the act name of 'CodedDiagnosis' are Diagnoses. These are identified using the SnCT Concept code '163001000000103'.
[1..*] component

An act relationship used to convey that the ActRef act forms a component of the acts within the CareRecordElementCategory.

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] actRef (ActRef)

A link to information about an act (clinical statement defined elsewhere within this message) that is a component of this care record element category.

  1. Where an Investigation Result is being referenced, the classCode 'OBS' and moodCode 'EVN' will be used. The id will be that UUID which uniquely identifes the instance of the Investagation Result.
  2. Where an Investigation is being referenced, the classCode 'OBS' and moodCode 'EVN' will be used to point to a DIProcedure act. The id will be that UUID which uniquely identifes the instance of the Investagation.
  3. Where a Diagnoses is being referenced, the classCode 'OBS' and moodCode 'EVN' will be used to point to a CodedDiagnosis act. The id used will be that which uniquely identifies that act.
FulfillerRequest

Details of the information about the Fulfilller Request that this message fulfills.

(W5 Ref: Section 5)

Used by: DIReport
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:PRMS} ){ Fixed="PRMS " }

A code to indicate this is a promise to fulfill a request.

  • Fixed value: "PRMS"
[1..2] id (LIST<II>)

The identifier for the Fulfiller Request. It is in the form of a list. 

This ID consists of 2 parts:

  1. the globally unique number to identify the Fulfiller Request (DCE UUID)
  2. the Fulfiller System OID + the fulfiller system Fulfiller Request ID.        This is included to allow the viewer to see the 'friendly' identifier but may not necessarily be present.

(W5 Ref: Section 5.2)

[1..1] statusCode (CS {CNE:ActStatus} )

A code from the HL7 V3 subset called 'ActStatus' which describes the status of the act, in this case the status of the Fulfiller Request.

Allowed values are: 

  1. 'Active' - there are some outstanding Procedures/reports.
  2. 'Completed'  - this is the final status

(W5 Ref: Section 5.3)

[0..1] inFulfillmentOf

A link between the Fulfilller Request details and those of the Placer Request, which it fulfills.

[1..1] typeCode (CS {CNE:FLFS} ){ Fixed="FLFS " }

Indicates that this is in fulfills a request.

  • Fixed value: "FLFS"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "ON" - Overriding and Non-propagating

The default value of "ON" indicates that the association does not add to the existing context associated with the Act, and will not propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "false".

[1..1] priorPlacerRequest (PlacerRequest)

A link to the details of the requesting system's identifer for the request.

MessageRef

Details about the previous DIReport message instance which this new message is to replace.

Used by: DIReport
[1..1] classCode (CS {CNE:INFRM} ){ Fixed="INFRM " }

A code indicating that the DIReport message being replaced was for information purposes

  • Fixed value: "INFRM"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate that it was an event.

  • Fixed value: "EVN"
[1..1] id (II)

UUID identifying the instance of the message being replaced. The identifier is carried in the FocalAct of the original message. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance it is the globally unique identifier for the instance of the DIReport message that is to be replaced. 

(W5 Ref: Section 1.5)

SummaryReportSegment

Details of the Summary Report contained within this message.

Note:

  1. This could summarize any combination of Procedure Reports that are either contained within this message or have been previously published to this patient's record.
  2. The author and verifer of this Summary Report could be different persons to those who authored/verified the Procedure Report(s) 

(W5 Ref: Section 6.2)

Used by: ReportGrouper
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

UUID identifying this instance of this act. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance it is the globally unique identifier for this instance of the SummaryReportSegment

(W5 Ref: Section 6.2.1)

[1..1] code (CD {CNE:SnomedCT} )

A code from the SnomedCT UK subset that describes this act as a DI Summary Report.

  • Fixed Value: "163671000000100"
  • Datatype flavour:  Coded with Qualifier(s)

(W5 Ref: Section 6.2.2)

[1..1] effectiveTime (TS)

A 'Null Value' only is used here in this act.

[1..1] value (ED)

This is the report text for the DI Summary Report.

The ED datatype has been used to allow ASCII or HTML text formats to be included here.

NOTE:      The allowed use of HTML will be a further constraint to that published for GP2GP messages. See the Data Types folder for more information. 

(W5 Ref: Section 6.2.4)

[0..1] author

A link between the Summary Report focalAct and the details of the person who authored the contents of the Summary Report.

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

A code indicating that this is the author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET used to identify the person who has authored the content of the Summary Report.

(W5 Ref: Section 6.2.3)

[0..1] verifier

A link between the Summary Report focalAct and the details of the verifier of the report it contains.

[1..1] typeCode (CS {CNE:VRF} ){ Fixed="VRF " }

A code indicating that this is the verifier of the contents of the report(s) contained author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET:  R_AgentNPFITPersonSDS used to identify the person who has verified the content of the Summary Report.

(W5 Ref: Section 6.2.7)

[0..*] component

A link between the Summary Report and the details of any diagnosis codes that the reporter may have added in addition to the text. 

(W5 Ref: Section 6.2.6)

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.
In this instance, the inversionInd defaults to "false".

[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the relationship does not apply.
In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf2"
[1..1] codedDiagnosis (CodedDiagnosis)

A link to the details of the Coded Diagnosis.

This is expressed as a shadow to the CodedDiagnosis act described in the SummaryReport Segment.

(W5 Ref: Section 6.3.1.6)

[1..*] reference

A link between the Summary Report focalAct and the details of any DI Procedure Reports (previous or current) that this report has summarised.

(W5 Ref: Section 6.2.5)

[1..1] typeCode (CS {CNE:REFR} ){ Fixed="REFR " }

A code indicating that this is a reference 

  • Fixed value: "REFR"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.
In this instance, the inversionInd defaults to "false".

[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the relationship does not apply.
In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf1"
[1..1] referredToActRef (ActRef)

A link to the details of the DI Procedure Reports referenced within the Summary Report. This is expressed as an ActRef.

In this instance the ActRef refers to the DI Procedure Report and hence the classCode used will be 'OBS', the moodCode will be 'EVN' and the id will be that of the individual Procedure Report being referenced.

ProcedureReportSegment

Details of the DI Procedure Report(s) contained within this message.

This section is repeated for each DI Procedure Report.

(W5 Ref: Section 6.3.1)

Used by: ReportGrouper
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..2] id (LIST<II>)

The identifier for the DI Procedure Report. It is in the form of a list. 

This ID consists of:

  1. the globally unique number to identify the Procedure Report (DCE UUID)
  2. the fulfiller system OID + the fulfiller system Procedure Report ID.     This is included to allow the viewer to see the 'friendly' identifier but may not necessarily be present.

(W5 Ref: Section 6.3.1.1)

[1..1] code (CD {CNE:SnomedCT} )

A code from the SnomedCT UK subset that describes this act as a DI Procedure Report.

  • Fixed Value: "163661000000107"
  • Datatype flavour:  Coded with Qualifier(s)

(W5 Ref: Section 6.3.1.2)

[1..1] effectiveTime (TS)

A 'Null Value' only is used here in this act.

[1..1] value (ED)

This is the report text for the DI Procedure Report.

The ED datatype has been used to allow ASCII or HTML text formats to be included here.

NOTE:      The allowed use of HTML will be a further constraint to that published for GP2GP messages. See the Data Types folder for more information. 

(W5 Ref: Section 6.3.1.4)

[0..1] author

A link between the Procedure Report focalAct and the details of the author of the report it contains.

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

A code indicating that this is the author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET used to identify the person who has authored the content of this Procedure Report.

(W5 Ref: Section 6.3.1.3)

[0..1] verifier

A link between the Procedure Report focalAct and the details of the verifier of the report it contains.

[1..1] typeCode (CS {CNE:VRF} ){ Fixed="VRF " }

A code indicating that this is the verifier of the contents of the report(s) contained author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET:  R_AgentNPFITPersonSDS used to identify the person who has verified the content of this Procedure Report.

(W5 Ref: Section 6.3.1.7)

[0..*] component

A link between the Procedure Report and the details of any diagnosis codes that the reporter may have added in addition to the text. 

[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

A code indicating that this is a component 

  • Fixed value: "COMP"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.
In this instance, the inversionInd defaults to "false".

[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the relationship does not apply.
In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf2"
[1..1] codedDiagnosis (CodedDiagnosis)

A link to the details of the Coded Diagnosis.

This is expressed as a shadow to the CodedDiagnosis act described in the SummaryReport Segment.

(W5 Ref: Section 6.3.1.6)

[1..*] reference

A link between the Procedure Report and the details of the DI Procedure Instance(s) for which it is the report.

(W5 Ref: Section 6.3.1.5)

[1..1] typeCode (CS {CNE:REFR} ){ Fixed="REFR " }

A code indicating that this is a reference 

  • Fixed value: "REFR"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.
In this instance, the inversionInd defaults to "false".

[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the relationship does not apply.
In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf1"
[1..1] referredToActRef (ActRef)

A link to the details of the DI Procedure Instance(s) for which this is a Procedure Report. This is expressed as an ActRef.

In this instance the ActRef refers to the DI Procedure and hence the classCode used will be 'OBS', the moodCode will be 'EVN' and the id will be that of the individual DI Procedure being referenced.

(W5 Ref: Section 6.3.1.5)

DIProcedure

Details of the DI Procedure Instance(s) that have been reported within this message.

This section is repeated for each DI Procedure Instance performed.

(W5 Ref: Section 7.1)

Used by: ReportGrouper
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an Observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..2] id (LIST<II>)

The identifier for the DI Procedure Instance. It is in the form of a list. 

This ID consists of 2 parts:

  1. the globally unique number to identify the DI Procedure Instance (DCE UUID)
  2. the fulfiller system OID + fulfiller system DI Procedure Instance ID.     This is included to allow the viewer to see the 'friendly' identifier.

(W5 Ref: Section 7.1.1)

[1..1] code (CD {CNE:DIProcedureSnCT} )

A SNOMED code from the listing called 'DIProcedureSnCT', which is a subset of  the 'ObservationTypeSnCT'. 

It describes the Diagnostic Imaging Procedure undertaken in this instance. The datatype flavour to be used is Coded with Qualifier(s)

Note: 

  1. The approved listing is being finalised at the time of writing, but the allowable values are expected to be within SnCT concept code '363679005' and it's descendants. 
  2. This could be either a single precoordinated code or a collection of post-coordinated codes

(W5 Ref: Section 7.1.2)

[1..1] statusCode (CS {CNE:ActStatus} )

A code from the HL7 V3 subset called 'ActStatus' which describes the status of the act, in this case the status of the DI Procedure Instance.

Allowed values are: 

  1. 'Active'  - procedure not complete.
  2. 'Aborted'  - procedure started but abandoned for a reason.
  3. 'Completed'  (default value) - procedure finished

(W5 Ref: Section 7.1.5)

[1..1] effectiveTime (TS)

This is the date and time stamp at which point the DI Procedure Instance was given the status described above. In most cases this will be the time the procedure instance was completed.

Format: yyyymmddhhmmss

(W5 Ref: Section 7.1.3)

[0..1] performer

A link between the DI Procedure Instance and the details of the service provider who is responsible for performing that particular instance.

This may be a completely different Service Provider than that which has previously been identified as being responsible for the DI Report as a whole. e.g. for a Contracted-out service like MRI or NucMed

[1..1] typeCode (CS {CNE:PRF} ){ Fixed="PRF " }

A code indicating that this is the organization that is responsible for the actual performance of this DI Procedure Instance

  • Fixed value: "PRF"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120501UK03)

A link to the NPfIT CMET:  R_AgentNPFITOrganizationSDS used to identify the organization responsible for the actual performance of the DI Procedure and the creation of any associated data objects (Key Images).

Note:   There is an expectation that SDS Org codes will identify at least the DI Service Provider, if not the departments within it.

(W5 Ref: Section 7.1.4)

[0..*] pertinentInformation

A link between the DI Procedure and the details of any data objects (key images) which the reporting clinician has identified as being of importance to the understanding of the report.

This will only be used in a PACS enabled system where access issues have been addressed.

[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates that this is pertinent information.

  • Fixed value: "PERT"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to reference individual KeyImages in a specific sequence/order within the DI Procedure act. This will only be present if there are 2 or more KeyImages and the Fulfiller System wishes to utilise this function.

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "true".

[1..1] pertinentKeyImages (KeyImages)

A link to the details of any images identified by the reporting clinician as being key to the reading of the report(s) contained within this message.

(W5 Ref: Section 7.1.6)

[0..*] subject

A link between the DI Procedure and the details of any Numeric Results that may have been gathered during the procedure.

[1..1] typeCode (CS {CNE:SUBJ} ){ Fixed="SUBJ " }

A code to indicate this is a subject of.

  • Fixed value: "SUBJ"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.
In this instance, the inversionInd defaults to "false".

[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to identify individual Numeric Results in a specific sequence/order within a specific DI Procedure's details. This will only be present if there are 2 or more Numeric Results and the Fulfiller System wishes to utilise this function.

[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the relationship does not apply.
In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID 2.16.840.1.113883.2.1.3.2.4.18.2
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf2"
[1..1] numericResult (NumericResult)

A link to the details of any numerical results taken during the DI Procedure(s).

(W5 Ref: Section 7.1.7)

PlacerRequest

Details of the requesting (Placer) system's identifier for the Diagnostic Imaging request for which this message is a report.

Note: At the current time , this is an optional component. When Diagnostic Requests are managed electronically this will become a required component. 

(W5 Ref: Section 5.1)

Used by: FulfillerRequest
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:RQO} ){ Fixed="RQO " }

A code to indicate this is a request for a service.

  • Fixed value: "RQO"
[1..2] id (LIST<II>)

The identifier for the Placer Request. It is in the form of a list. 

This ID consists of:

  1. the globally unique number to identify the Placer Request (DCE UUID)
  2. the Placer System OID + placer system Placer Request ID.               This is included to allow the viewer to see the 'friendly' identifier but may not necessarily be present.

(W5 Ref: Section 5.1.1)

[1..1] author

A link between the Placer Request focalAct and the details of the author of the request it identifies.

(W5 Ref: Section 5.4)

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

A code indicating that this is the author of the message

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

In this instance, a code that this professional propagates through to the clinical statements as the care professional unless specifically overriden for individual acts.

[1..1] agent (UKCT_MT120301UK02)

A link to the NPfIT CMET used to identify the person who has authored the request it identifies.

(W5 Ref: Section 5.4)

CodedDiagnosis

Details of the Coded Diagnosis given by the reporting clinician, additionally to the textual report.

(W5 Ref: Sections 6.2.6 & 6.3.1.6)

Used by: SummaryReportSegment, ProcedureReportSegment
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

UUID identifying this instance of this act. This identifier is universally unique across all records. It is in the form of a DCE UUID.

In this instance it is the globally unique identifier for this instance of this Coded Diagnosis

[1..1] code (CD {CNE:ObservationTypeSnCT} )

A SNOMED code from the subset 'ObservationTypeSnCT'.

It describes the Clinical Diagnosis assigned by the reporting clinician. The datatype flavour to be used is either Coded with Qualifier(s) or Coded with Translation

Allowed code ranges are: SnCT concept codes '64572001' and '404684003' and their descendants [excluding '36558006' and '307824009' and their descendants].

(W5 Ref: Sections 6.2.6 & 6.3.1.6)

[1..1] effectiveTime (TS)

This is the date and time stamp at which point the Coded Diagnosis was transcribed into Radiology Information System.

Format: yyyymmddhhmmss

ActRef

This is a modelling tool to enable an Act to be referenced, where necessary, within the message without repeating all the descriptions of that act where it is repeated.

The Act being referenced could be one included within the message or one that has already been published to PSIS.

Used by: SummaryReportSegment, ProcedureReportSegment, CRECategory
[1..1] classCode (CS {CNE:ACT} ){ Fixed="ACT " }

'ACT' is the highest level of classCode.

For this ActRef to be ultised properly by the relationships identified within the model, this classCode MUST be changed to the code of the item being referenced.

The classCode to be used in each instance has been described at the point from which this ActRef has been referenced.

[1..1] moodCode (CS {CNE:ActMood} )

'ActMood' is the highest level of moodCode.

For this ActRef to be ultised properly by the relationships identified within the model, this moodCode MUST be changed to the code of the item being referenced.

The moodCode to be used in each instance has been described at the point from which this ActRef has been referenced.

[1..1] id (II)

UUID identifying this instance of the act being referenced using this ActRef. This identifier is universally unique across all records. It is in the form of a DCE UUID.

The ID to be used in each instance has been described at the point from which this ActRef has been referenced.

KeyImages

Details of the data object(s) [e.g. images] that the reporting clinician has identified as being of key importance to the reading this report. Repeat this section for each image identified.

(W5 Ref:  Section 7.1.6)

Note:

  • The data object(s) that are pointed to are more likely to be digital images and hence only established PACS users will need to utilize this section.
  • the URL used must point to an individual data object, not a group or study of them
Used by: DIProcedure
[1..1] classCode (CS {CNE:DGIMG} ){ Fixed="DGIMG " }

A code to indicate this is a Diagnostic Image.

  • Fixed value: "DGIMG"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] value (ED)

This is a list of the references to the identified Key Images.

Each list entry takes the form of the 'Encapsulated Data Attachment Reference' flavour of the ED datatype describing the mediaType (e.g. JPEG) and the reference (URL).

NumericResult

Details of any numerical results taken during the DI Procedure Instance.

Note: 

  1. This section is repeated for each numeric result
  2. This does not force the clinicians to enter their results but anticipates automated systems (e.g. Ultrasound) to be allowed to input at this point.

(W5 Ref: Section 7.1.7)

Used by: DIProcedure
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

UUID identifying this instance of this act. This identifier is universally unique across all records. It is in the form of a DCE UUID.

In this instance it is the globally unique identifier for this instance of this Numeric Result

[1..1] code (CD {CNE:DINumericResultsSnCT} )

A SNOMED code from the listing called 'DINumericResultsSnCT', which is a subset of the 'ObservationTypeSnCT'.

It describes this as being an Investigation Result of a particular type. The datatype flavour to be used is either Coded with Qualifier(s) or Coded with Translation

Allowed code range is:   SnCT Concept code  '277775005' and it's descendants.   

For Example:

  1. Crown Rump Length (CRL) = '281688001'
  2. Bi-Parietal Diameter (BPD) = '276351002'
  3. Femur length (FL) = '396551005'
  4. Fetal Heart Rate (FHR) = '249043002'
[1..1] effectiveTime (TS)

This is the date and time stamp at which point the Numeric Result was determined from the DI Procedure Instance.

Format: yyyymmddhhmmss

(W5 Ref: Section 7.1.7.7)

[1..1] value (IVL<PQ>)

The actual value of the numerical result. This represented in 2 parts:    

  1. Value (an integer representing the measured amount) 
  2. Units (the SnomedCT code for the unit of measurement e.g. cm)

(W5 Ref: Sections 7.1.7.2 & 7.1.7.3)

[0..1] interpretationCode (CS {CNE:ObservationInterpretation} )

One or more codes from the HL7 'ObservationInterpretation'  listing specifying a rough qualitative interpretation of the observation.

For Diagnostic Imaging these codes will be limited to:

  1. 'Normal'
  2. 'Abnormal'

(W5 Ref: Section 7.1.7.6)

[0..*] referenceRange

A link between the Numeric Result and the details of any interpretation range that value falls into.

[1..1] typeCode (CS {CNE:REFV} ){ Fixed="REFV " }

A code to indicate this is a Reference Value Range.

  • Fixed value: "REFV"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the ActRelationship to the child act.
In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.
If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.
The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.
In this context the seperatableInd defaults to "false".

[1..1] referenceInterpretationRange (InterpretationRange)

A link to the details of the interpretation range used as reference for the numerical result.

InterpretationRange

Details of the Interpretation Range used when taking the numerical results identified. 

(W5 Ref: Section 7.1.7.4)

Used by: NumericResult
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

A code to indicate this is an observation.

  • Fixed value: "OBS"
[1..1] moodCode (CS {CNE:EVN.CRT} ){ Fixed="EVN.CRT " }

A code to indicate this is an event criterion.

  • Fixed value: "EVN.CRT"
[1..1] value (IVL<PQ>)

The reference range of values used to identify the normality is a pair of values (high and low) of the same data type as the observation to which they are applied, carried as an interval (IVL).

In some instances there may only be a Low or a High rather than a pair of values. Some systems supply ranges as a string.

(W5 Ref: Section 7.1.7.4)