Diagnostic Imaging Report - tabular view

No Current Link To VocabularyCoded With Extensions
POII_RM000002UK01
DIReport

A Diagnostic Imaging Report is sent by the Service Provider to the requestor.   Details about the report(s) are contained within this communication.

Used by:
[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. 

The first (mandatory) identifier carries the local identifier consisting of a Fulfiller System OID and the Fulfiller System Fulfiller Report ID. As well as conveying a real world business identifier that the observation may have, the presence of an id allows this act to be "replaced" in a future message should that be necessary (see replacementOf).

The second id is for possible future use (e.g. "snapshot" DCE UUID).

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

A code from the SnomedCT UK subset that describes this act as a 'Diagnostic imaging report'.

  • Fixed value: "181191000000107"
  • 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:

'active'  - there are some outstanding Procedures/reports.
'completed'  (default value) - this is the final status

[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 use case) or the content verification (for verified release use case)

[1..1] priorityCode (CV {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'
[1..1] recordTarget

A link between the DIReport act and the patient role class.

[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 Patient role class.

[1..1] author

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

Note:

  1. This is the author of the communication.                 
  2. This author may be the same as that of the report(s) the communication contains, but not necessarily so. Although this author does conduct down to the pertinent/component acts it will be replaced by the author details added at those acts.
[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT" }

A code indicating that this is the author of the communication

  • 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[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).

[0..1] verifier

A link between the ReportGrouper and 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. If the verifier is a different person to the author and doesn't agree (i.e doesn't mark the report on the RIS as 'verified'), then the author is asked to review and amend in a cyclic fashion.  This cycle should have been completed and both parties satisfied that the contents are correct (and therefore the verifier has marked the report as verified ) before this report communication is created.
  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.
  4. Not all reports will have a verifier due to staffing and/or local policies. As this is the case for a significant number of reports it makes sense for the author to continue to be the one responsible for the rest of the grouper content.
  5. For most situations the author and the verifier will be the same person.
  6. However, irrespective of this the 'author' takes the responsibility for the inclusion or exclusion of items in the grouper block
[1..1] typeCode (CS {CNE:VRF} ){ Fixed="VRF" }

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

  • 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

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

Full details of the person and role profile are available from SDS.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the Role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67
  • The extension attribute shall contain the SDS Role Profile ID

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65
  • The extension attribute shall contain the SDS User ID
[1..1] primaryInformationRecipient

A link between the DIReport act 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 communication

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

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 overrides 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_MT120301UK02]

A link to the NPfIT CMET R_AgentNPFITPersonSDS used to identify the person to whom this message is sent with the expectation that they act on it's contents.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67.
  • The extension attribute shall contain the SDS Role Profile ID.

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65.
  • The extension attribute shall contain the SDS User ID.
[1..1] responsibleParty

A link between the DIReport act and the Diagnostic Imaging Service Provider responsible for the DI Report.

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

A code indicating that this is the Diagnostic Imaging Service Provider with primary responsibility for the Report

  • Fixed value: "RESP"
[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 overrides 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 authoring 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 the Diagnostic Imaging Service Provider responsible for the Report.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67.
  • The extension attribute shall contain the SDS Role Profile ID.

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65.
  • The extension attribute shall contain the SDS User ID.
[0..*] tracker

A link between the DIReport act and the details of any other pre-named intended recipients of a copy of the DIReport message.

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

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

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

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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

A link to the NPfIT CMET R_AgentNPFITPersonSDS used to identify the person(s) to whom a copy of this message is expected to be sent.

Full details of the person and role profile are available from SDS.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the Role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67
  • The extension attribute shall contain the SDS Role Profile ID

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65
  • The extension attribute shall contain the SDS User ID
[0..1] component1

A link between the DIReport act and the SummaryReportSegment act 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 component relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Component" mechanism.

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 SummaryReportSegment act contained within this communication.

[1..*] component
A link between the DIReport act and the ProcedureReportSegment act 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 ReportGroup 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 component relationship.
In this context the seperatableInd defaults to "false".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Component" mechanism.

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 DIProcedureReport act contained within this communication.

[1..*] inFulfillmentOf1

A link between the DIReport act and the FulfilllerRequest act that this DIReport fulfills.

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

Indicates that this Report fulfills a request.

  • Fixed value: "FLFS"
[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.

  •  Fixed value: "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)

An indicator specifying that this relationship should not be negated

  • Fixed value: "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 actRelationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorFulfillerRequest (FulfillerRequest)

A link to the FulfillerRequest that this Report fulfills.

[0..1] inFulfillmentOf

A link between the DIReport act and the PlacerRequest act that is pertinent to this Report.

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

Indicates that this fulfills a request.

  • Fixed value: "FLFS"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

In this context the negationInd has a fixed value: "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 ActRelationship.
In this context the seperatableInd has a fixed value: "true".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Reference" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf1".
[1..1] priorPlacerRequest (PlacerRequest)

A link to the details of the Placer Request that this Report fulfills.

[0..1] replacementOf

This identifies a report that is being replaced by a new report event, because the previous report was incorrect and is being replaced by a new report act.

This is NOT used for updating or correcting a report with additional or more up to date information, but rather when the original report should be disregarded and the new report take its place. This is not a supersession of one report by another.

In general a more up to date report can replace another without need for an explicit replacementOf relation, where the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

 In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

An indicator specifiying that the source act may not be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorReportEvent (PriorReportEvent)

Identifies the Act being replaced and sets its status to 'Obsolete'. All replaced acts become 'Obsolete'

Patient

Details about the patient.

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)

To provide the nationally recognised identifier for the patient, the NHS number.

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

An NHS number is carried in the following way:

  • The root attribute will contain an OID with the value "2.16.840.1.113883.2.1.4.1"
  • The extension attribute will contain the 10 digit NHS number.

Only new permanent NHS numbers can be used to identify patients.

AuthorChoice

The author of the communication.

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

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 communication.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

The DeviceSDS.id field shall be used to carry the Device Id as follows:

  • The root attribute shall contain the OID for the NHS SDS Accredited System Identifier
  • The extension attribute shall contain the Device Id
             ... 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).

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67.
  • The extension attribute shall contain the SDS Role Profile ID.

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65.
  • The extension attribute shall contain the SDS User ID.
SummaryReportSegment

The Summary Report contained within this communication.

Note:

  1. This could summarize any combination of Procedure Reports that are either contained within this communication 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)
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:EVN} ){ Fixed="EVN" }

A code to indicate this is an event.

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

A list of  identifiers for this Summary Report. The first (mandatory) identifier carries the local identifier consisting of the Fulfiller System OID + the fulfiller system Summary Report ID.       

As well as conveying a real world business identifier that the observation may have, the presence of an id allows this act to be "replaced" in a future message should that be necessary (see replacementOf).

The second id is for possible future use (e.g. "snapshot" DCE UUID).

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

A code from the SnomedCT UK subset that describes this act as a 'Diagnostic imaging summary report'.

  • Fixed value: "181211000000106"

The datatype flavour Coded Plain is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the SnomedCT vocabulary;
  • The codeSystem attribute shall contain the OID for SnomedCT
  • The displayName attribute will carry a description for the code from the coding system .
[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
[1..1] effectiveTime (TS)

This is the date and time stamp at which the Summary Report contents were 'authored' or 'verified' by the reporter.

  • Format: yyyymmddhhmmss

Note: 

  1. If 'author' point used (in non-verified use case), this is more likely to be the time stamp at which the dictated report was transcribed onto the RIS, but could be the time at which the report was digitally dictated.
  2. If 'Verified' point used (in verified use case) this is the time stamp at which the report was verified by the reporter.
[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.

Encapsulated Data Plain Text (f)

Encapsulated Data Limited HTML (f)

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. 

[0..1] author

A link between the SummaryReportSegment act and the person who authored the contents of the Report.

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

A code indicating that this is the author of the content of the Summary 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

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

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67.
  • The extension attribute shall contain the SDS Role Profile ID.

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65.
  • The extension attribute shall contain the SDS User ID.
[0..1] verifier

A link between the SummaryReportSegment act 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 Summary report

  • 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

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

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the role of the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67.
  • The extension attribute shall contain the SDS Role Profile ID.

PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65.
  • The extension attribute shall contain the SDS User ID.
[0..*] component1

A link between the SummaryReportSegment act and any Numeric Results that may have been made as a result of this Report.

[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".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to identify individual Numeric Results in a specific sequence/order within a specific Summary Report'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 semantic of the relationship is negated.

 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)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] numericResult (NumericResult)

A link to any numerical result(s) that may have been made as a result of the Summary Report.

[0..*] component

A link between the SummaryReportSegment act and 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)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] codedDiagnosis (CodedDiagnosis)

A link to the CodedDiagnosis act.  Until issues concerning the possibility of a Coded Diagnosis appearing out of context are resolved, suppliers are recommended to implement but not release coded diagnosis functionality.

[0..*] pertinentInformation

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

Note: 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 SummaryReportSegment 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)

An indicator specifiying that the source act may be interpreted independently of the target act

  • Fixed value: "true"
[1..1] pertinentKeyImages (KeyImages)

A link to the KeyImages act, describing images identified by the reporting clinician as being key to the reading of the report(s) contained within this communication.

[0..1] replacementOf

Refers to a previous act that this act is intended to replace. Replacement is used where the replacing act has a different Act.code but is of the same act type. In other circumstances no replacementOf is needed, the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

 In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

An indicator specifiying that the source act may not be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorObservationEvent (PriorObservationEvent)

The act being replaced.

[1..*] reference

A link between the SummaryReportSegment act and the ProcedureReportSegment act for which it is the summary.

[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 specifiying that the ActRelationship.typeCode should not be interpreted as if the roles of the source and target acts were reversed

  • Fixed value: "false"
[1..1] negationInd (BL)

An indicator specifying that this relationship should not be negated

  • Fixed value: "false"
[1..1] seperatableInd (BL)

An indicator specifiying that the source act may be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] referredToPriorObservationEvent (PriorObservationEvent)

A reference to the ProcedureReportSegment act.

ProcedureReportSegment

The DI Procedure Report(s) contained within this communication.

Note: This section is repeated for each DI Procedure Report.

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: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.  

The first (mandatory) identifier carries the local identifier consisting of the fulfiller system OID + the fulfiller system Procedure Report ID.  As well as conveying a real world business identifier that the observation may have, the presence of an id allows this act to be "replaced" in a future message should that be necessary (see replacementOf).

The second id is for possible future use (e.g. "snapshot" DCE UUID).

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

A code from the SnomedCT UK subset that describes this act as a 'Diagnostic imaging procedure report'.

  • Fixed value: "181201000000109"

 The datatype flavour Coded Plain is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the SnomedCT vocabulary;
  • The codeSystem attribute shall contain the OID for SnomedCT
  • The displayName attribute will carry a description for the code from the coding system .
[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.
[1..1] effectiveTime (TS)

This is the date and time stamp at which the Procedure Report contents were 'authored' or 'verified' by the reporter.

  • Format: yyyymmddhhmmss

Note: 

  1. If 'author' point used (in non-verified use case), this is more likely to be the time stamp at which the dictated report was transcribed onto the RIS, but could be the time at which the report was digitally dictated.
  2. If 'Verified' point used (in verified use case) this is the time stamp at which the report was verified by the reporter.
[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:

Encapsulated Data Plain Text (f)

Encapsulated Data Limited HTML (f)

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. 

[0..1] author

A link between the ProcedureReportSegment act and 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 content of the ProcedureReportSegment act

  • 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

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

Full details of the person and role profile are available from SDS.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the Role of the Person in the following way:

The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67
The extension attribute shall contain the SDS Role Profile ID
PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65
The extension attribute shall contain the SDS User ID

[0..1] verifier

A link between the ProcedureReportSegment act and the verifier of this report.

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

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

  • 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 overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] agent      [CMET: UKCT_MT120301UK02]

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

Full details of the person and role profile are available from SDS.

Only the following Classes and Attributes from this CMET shall be included in this message.  Classes and attributes that are not detailed below are not to be used in this message.

AgentPersonSDS.id shall  carry An SDS identifier that uniquely identifies the Role of the Person in the following way:

The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.67
The extension attribute shall contain the SDS Role Profile ID
PersonSDS.id shall carry an SDS identifier that uniquely identifies the Person in the following way:

The root attribute shall contain an OID with the value 1.2.826.0.1285.0.2.0.65
The extension attribute shall contain the SDS User ID

[0..*] component1

A link between the ProcedureReportSegment act and the NumericResult act.

[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".

[0..1] sequenceNumber (INT)

An integer allowing the Fulfiller system to identify individual Numeric Results in a specific sequence/order within a specific Procedure Report'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 semantic of the relationship is negated.

 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)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] numericResult (NumericResult)

A link to any numeric result(s) that may have been made as a result of the Procedure Report.

[0..*] component

A link between the ProcedureReportSegment and 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 ActRelationship.
In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".

[1..1] codedDiagnosis (CodedDiagnosis)

A link to the CodedDiagnosis act. Until issues concerning the possibility of a Coded Diagnosis appearing out of context are resolved, suppliers are recommended to implement but not release coded diagnosis functionality.

[0..*] pertinentInformation

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

Note: 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 ProcedureReportSegment 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)

An indicator specifiying that the source act may be interpreted independently of the target act

  • Fixed value: "true"
[1..1] pertinentKeyImages (KeyImages)

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

[0..1] replacementOf

Refers to a previous ProcedureReportSegment  act  that this act is intended to replace. Replacement is used where the replacing act has a different Act.code but is of the same act type. In other circumstances no replacementOf is needed, the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

 In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

An indicator specifiying that the source act may be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorObservationEvent (PriorObservationEvent)

A link to the ProcedureReportSegment act that is being replaced.

[1..*] reference

A link between the ProcedureReportSegment act and the DIProcedureSummary act.

[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 specifiying that the ActRelationship.typeCode should not be interpreted as if the roles of the source and target acts were reversed

  • Fixed value: "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)

An indicator specifying that this relationship should not be negated

  • Fixed value: "false"
[1..1] seperatableInd (BL)

An indicator specifiying that the source act may be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] referredToDIProcedureSummary (DIProcedureSummary)

The DIProcedureSummary that may have been made as a result of Procedure Report.

FulfillerRequest

This act represents the RIS system's fulfiller request and is present to record the human readable fulfiller request number.

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>)

A list of  identifiers for this Fulfiller Request. The first (mandatory) identifier carries the local identifier consisting of the Fulfiller System OID + the fulfiller system Fulfiller Request ID.       

As well as conveying a real world business identifier that the observation may have; the presence of an id allows this act to be "replaced" in a future message should that be necessary (see replacementOf).

The second id is for possible future use (e.g. "snapshot" DCE UUID).

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

A code from the SnomedCT UK subset that describes this act as a 'FulfillerRequest'.

  • Fixed value of the Fulfiller request details (administrative concept): "183221000000104"

 The datatype flavour Coded Plain is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the SnomedCT vocabulary;
  • The codeSystem attribute shall contain the OID for SnomedCT
  • The displayName attribute will carry a description for the code from the coding system.
[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
[1..1] effectiveTime (TS)

The date and time stamp of the assertion in this message that the report is fulfilling this fulfiller number. This is the same as 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 use case) or the content verification (for verified release use case)

PlacerRequest

The Placer Request that is pertinent to this Report.

Note: This is an optional component. When Diagnostic Requests are managed electronically this will become a required component. 

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

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..1] id (II)

A human-readable number generated by an order placer system to uniquely identify a new order request. 

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

  • The root attribute shall contain the OID identifying the Placer System at that level which, when combined with the generated Placer Request ID, makes it unique
  • The extension shall contain the identifier for the Placer Request
PriorReportEvent

The DI Report act being replaced by a new report event, because the previous report was incorrect .

This is NOT used for updating or correcting a report with additional or more up to date information, but rather when the original report should be disregarded and the new report take its place. This is not a supersession of one report by another.

In general, a more up to date report can replace another without need for an explicit replacementOf relation, where the new act is just messaged with the same id and updated fields.

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

Indicates that this is an entry.

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

Indicates that this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

This carries the identifier of the report that is being replaced. It corresponds to the locally allocated id from the earlier DIReport act.

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

The Coded Simple datatype is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary and is constrained in this case to 'Obsolete'.
NumericResult

Any numeric results pertaining to this section of the report.

Note:

  1. This section is repeated for each NumericResult act.
  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.
  3. The author of the Report Grouper takes responsibility for the inclusion of the Numeric Result item(s)
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)

An Identifier (Identifier Global flavour) representing this act.

This identifier is universally unique across all records for this Numeric Result.

It is in the form of a DCE UUID. 

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

A SNOMED code from the listing called 'DINumericResultsSnCT' which describes any Numeric Results pertaining to this section of the Report.

 The datatype flavour to be used is either Coded with Qualifier(s) or Coded with Translation

  • The code attribute shall contain a code from the DiagnosisSnCT vocabulary
  • The codeSystem attribute shall contain the OID for SnomedCT 
  • The displayName shall carry a description associated with the code in the source code system
  • The originalText attribute may be used if required
  • qualifier(s) may be used if required
  • The translation attribute may be used if required
[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
[1..1] effectiveTime (TS)

This is the date and time stamp at which point the Numeric Result was determined.

  • Format: yyyymmddhhmmss
[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 UCUM code for the unit of measurement e.g. cm)
[0..1] interpretationCode (CS {CNE:ObservationInterpretation} )

A code from the HL7 'ObservationInterpretation'  listing specifying a rough qualitative interpretation of the observation are available for use.

For Diagnostic Imaging these codes shall be limited to:

  1. 'Normal'
  2. 'Abnormal'
[0..1] replacementOf

Refers to a previous NumericResult act  that this act is intended to replace. Replacement is used where the replacing act has a different Act.code but is of the same act type. In other circumstances no replacementOf is needed, the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

 In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

An indicator specifiying that the source act may not be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorObservationEvent (PriorObservationEvent)

A link to the NumericResult act being replaced.

[0..1] referenceRange

A link between the NumericResult and any InterpretationRange 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.

CodedDiagnosis

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

Note 1: Until issues concerning the possibility of a Coded Diagnosis appearing out of context are resolved, suppliers are recommended to implement but not release coded diagnosis functionality.

Note 2: Once a specific Coded Diagnosis value has been given once within a communication, it shall not be repeated anywhere else within the same communication.

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)

An Identifier (Identifier Global flavour) representing this act.

This identifier is universally unique across all records for this Coded Diagnosis.

It is in the form of a DCE UUID.

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

A SNOMED code from the subset 'DiagnosisSnCT' describing the Clinical Diagnosis assigned by the reporting clinician.

The datatype flavour to be used is either Coded with Qualifier(s) or Coded with Translation

  • The code attribute shall contain a code from the DiagnosisSnCT vocabulary
  • The codeSystem attribute shall contain the OID for SnomedCT 
  • The displayName shall carry a description associated with the code in the source code system
  • The originalText attribute may be used if required
  • qualifier(s) may be used if required
  • The translation attribute may be used if required
[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
[1..1] effectiveTime (TS)

The date and time stamp when the Reporting HCP identifies the diagnosis determined by this procedure, i.e. the relevant time that the diagnosed condition has.

  • Format: yyyymmddhhmmss
[0..1] replacementOf

A link to a previous  CodedDiagnosis  act that this act is intended to replace. Replacement is used where the replacing act has a different Act.code but is of the same act type. In other circumstances no replacementOf is needed, the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

In this case the negationInd is fixed at "false"

[1..1] seperatableInd (BL)

An indicator specifiying that the source act may be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorObservationEvent (PriorObservationEvent)

The CodedDiagnosis act being replaced.

KeyImages

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.

Note:

  1. 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.
  2. the URL used must point to an individual data object, not a group or study of them.
  3. When local systems are using the enclosed keyimage.value to view images, it is their responsibility to resolve the references. 
Used by: SummaryReportSegment, ProcedureReportSegment
[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).

DIProcedureSummary

A summary of the procedure instance carried in the encounter.

Used by: 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..2] id (LIST<II>)

A list of  identifiers for this DIProcedureSummary. The first (mandatory) identifier carries the local identifier consisting of the Fulfiller System OID + the DI Procedure Instance ID.       

As well as conveying a real world business identifier that the observation may have, the presence of an id allows this act to be "replaced" in a future message should that be necessary (see replacementOf).

The second id is for possible future use (e.g. "snapshot" DCE UUID).

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

A SNOMED code from the listing called 'DIProcedureSnCT' which describes the summary of the procedure instance pertaining to this section of the Report.

 The datatype flavour to be used is either Coded with Qualifier(s) or Coded with Translation

  • The code attribute shall contain a code from the DiagnosisSnCT vocabulary
  • The codeSystem attribute shall contain the OID for SnomedCT 
  • The displayName shall carry a description associated with the code in the source code system
  • The originalText attribute may be used if required
  • qualifier(s) may be used if required
  • The translation attribute may be used if required
[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
[1..1] effectiveTime (IVL<TS>)

The date and time stamp at when the DI Procedure was performed, checked for quality and then completed.

  • Format: yyyymmddhhmmss
[0..1] replacementOf

A link between this  DIProcedureSummary  act and the previous   act which this is intended to replace. Replacement is used where the replacing act has a different Act.code but is of the same act type. In other circumstances no replacementOf is needed, the new act is just messaged with the same id and updated fields.

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

Indicates that this is in replacement of

  • Fixed value: "RPLC"
[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.

  •  Fixed value: "false"
[1..1] negationInd (BL)

An indicator specifying that this relationship should not be negated

  • Fixed value: "false"
[1..1] seperatableInd (BL)

An indicator specifiying that the source act may be interpreted independently of the target act

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

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] priorPriorObservationEvent (PriorObservationEvent)

The DIProcedureSummary act being replaced.

PriorObservationEvent

The act being replaced by a new event, because the previous act was incorrect . This is NOT used for updating or correcting an act with additional or more up to date information, but rather when the original act should be disregarded and the new act take its place. This is not a supersession of one act by another. In general, a more up to date act can replace another without need for an explicit replacementOf relation, where the new act is just messaged with the same id and updated fields.

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

Indicates that this is an entry.

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

Indicates that this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

This carries the identifier of the act that is being replaced. It corresponds to the locally allocated id.

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

The Coded Simple datatype is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary and is constrained in this case to 'Obsolete'.
InterpretationRange

The InterpretationRange act used when taking the NumericResults identified.

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.