Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Text Observation

[Observation: templateId 2.16.840.1.113883.10.20.6.2.12]

DICOM Template 2000 specifies that Imaging Report Elements of Value Type Text are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Text DICOM Imaging Report Elements in this context are mapped to CDA text observations that are section components and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.
A Text Observation is required if the findings in the section text are represented as inferred from SOP Instance Observations.

  1. SHALL contain exactly one [1..1] templateId ( CONF:9290, CONF:10534 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.12"
  2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:9288)
  3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:9289)
  4. SHALL contain exactly one [1..1] code (CONF:9291)
  5. SHOULD contain zero or one [0..1] effectiveTime (CONF:9294)
  6. MAY contain zero or one [0..1] text (CONF:9295)
    1. text, if present, SHOULD contain zero or one [0..1] reference (CONF:15938)
      1. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15939)
        1. reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15940)
  7. SHALL contain exactly one [1..1] value with data type ED (CONF:9292)
  8. MAY contain zero or more [0..*] entryRelationship (CONF:9298, CONF:9299, CONF:15941)
    1. Contains @typeCode="SPRT" SPRT
    2. Contains exactly one [1..1] SOP Instance Observation (templateId: 2.16.840.1.113883.10.20.6.2.8)
  9. MAY contain zero or more [0..*] entryRelationship (CONF:9301, CONF:9302, CONF:15942)
    1. Contains @typeCode="SPRT" SPRT
    2. Contains exactly one [1..1] Quantity Measurement Observation (templateId: 2.16.840.1.113883.10.20.6.2.14)

Text Observation example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1057592002"/>
  <code code="958702401"/>
  <text>Text Value</text>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <value xsi:type="ED">Text Value</value>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="239001245"/>
      <code code="302659583"/>
      <text>Text Value</text>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="439037399"/>
          <code code="1138691832"/>
          <text>Text Value</text>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <value xsi:type="CD" code="2069444001"/>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="1063406599"/>
          <code code="2136796051"/>
          <text>Text Value</text>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <entryRelationship>
            <observation/>
          </entryRelationship>
        </observation>
      </entryRelationship>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="473143270"/>
      <code code="1692198516"/>
      <text>Text Value</text>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <value xsi:type="PQ"/>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="1000218091"/>
          <code code="1218105494"/>
          <text>Text Value</text>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <observation/>
          </entryRelationship>
        </observation>
      </entryRelationship>
    </observation>
  </entryRelationship>
</observation>