helios klinikum wuppertal rsna 2006

HELIOS Klinikum Wuppertal

RSNA 2006 PD Dr. Thomas HackländerDepartment of Radiology

DICOM SRGerman Radiology Report

Thomas Hackländer

RSNA 2006 PD Dr. Thomas HackländerDepartment of Radology

Introduction/Scope

• German law requires written report for X-ray and nuclear medicine examinations

• X-Ray and Radiation Control Regulation („Röntgenverordnung“, „Strahlenschutzverordnung“) does not specify the content of the report

• National standard DIN 6827-5, „Recording in medical application of ionizing radiation – Part 5: Radiological report“ specifies the content of the report

• Translating DIN 6827-5 into a DICOM SR template


Limitations of Current Standard

• „TID 2000 Basic Diagnostic Imaging Report“ defines only the skeletal structure of the report

• TID 2000 does not requires– Medical content

– Content concerning radiation protection

• „DIN 6827-5 Radiological report“ requires medical content and gives the option to document radiation protection content


DIN 6827-5 Radiological report

• Standard was developed with DICOM SR in mind• Standard is structured into templates grouping

informationRadiologischer Befundbericht

Angaben zum Patienten

nach

Angaben im Rahmen der Röntgenverordnung

nach

Angaben zur Untersuchung

nach

Medizinischer Inhalt nach

Angaben zum Befundbericht

nach

Name Geburtsname Geburtsdatum Geschlecht Identifikationsnummer

Ebene 1

Ebene 2


Description of Proposal Header Elements of the Report

Referenced IOD Module Attribute Name Tag VR Type

PS 3.3 - C.7.1.1 Patient Module Patient's Name (0010,0010) PN 2

PS 3.3 - C.7.1.1 Patient Module Other Patient Names (0010,1001) PN 3

PS 3.3 - C.7.1.1 Patient Module Patient's Birth Date (0010,0030) DA 2

PS 3.3 - C.7.1.1 Patient Module Patient's Sex (0010,0040) CS 2

PS 3.3 - C.7.1.1 Patient Module Patient ID (0010,0020) LO 2

PS 3.3 - C.7.2.1 General Study Module Study Date (0008,0020) DA 2

PS 3.3 - C.7.2.1 General Study Module Study Time (0008,0030) TM 2

PS 3.3 - C.7.2.1 General Study Module Referring Physician's Name (0008,0090) PN 2

PS 3.3 - C.7.2.1 General Study Module Referring Physician Identification Sequence

(0008,0096) SQ 3

PS 3.3 - C. 17.2 SR Document General Module Author Observer Sequence (0040,A078) SQ 3

PS 3.3 - C. 17.2 SR Document General Module Verification Flag (0040,A493) CS 1

PS 3.3 - C. 17.2 SR Document General Module Verifying Observer Sequence (0040,A073) SQ 1C

PS 3.3 - C. 17.2 SR Document General Module >Verifying Observer Name (0040,A075) PN 1

PS 3.3 - C. 17.2 SR Document General Module >Verifying Observer Identification Code Sequence

(0040,A088) SQ 2

PS 3.3 - C. 17.2 SR Document General Module >Verifying Organization (0040,A027) LO 1

PS 3.3 - C. 17.2 SR Document General Module >Verification DateTime (0040,A030) DT 1


Description of ProposalDICOM SR Template

NL

Rel with Parent

Value Type Concept Name VM RQ Condition Value Set Constraint

1 CONTAINER EV (11528-7, LN, “Radiology Report“)

1 M Root node

2 > HAS CONCEPT MOD

INCLUDE DTID(1204) Language of Content Item and Descendants

1 M

3 > HAS OBS CONTEXT

INCLUDE DTID(1001) Observation Context

1 M

4 > INCLUDE DTID (xx03) Information concerning the X-Ray Regulation

1 UC XOR Row 5

5 > INCLUDE DTID (xx04) Information concerning the Radiation Control Regulation

1 UC XOR Row 4

6 > INCLUDE DTID (xx05) Examination

1 M

7 > INCLUDE DTID (xx06) Medical Content

1 M


Information concerning the X-Ray Regulation Template

NL

Rel with Parent


1 CONTAINS TEXT EV (121066, DCM, “Prior Procedure Descriptions”)

1 M

2 CONTAINS CODE EV (111532, DCM, “Pregnancy Status”)

1 MC Nur bei Frauen im gebärfähigen Alter

CID 6096 (Pregnancy Status)

3 CONTAINS TEXT EV (121109, DCM, “Indications for Procedure”)

1 M

4 CONTAINS PNAME EV(1000, 99NAR, “Physician Responsible for Indication”)

1 M

5 CONTAINS PNAME EV (1001, 99NAR,"Performing Person")

1 M

6 CONTAINS TEXT EV(1003, 99NAR, “Radiation Exposure “

1 M


Information concerning the Radiation Control Regulation Template

NL

Rel with Parent


1 CONTAINS TEXT EV (121066, DCM, “Prior Procedure Descriptions ”)

1 M

2 CONTAINS CODE EV (111532, DCM, “Pregnancy Status”)

1 MC Nur bei Frauen im gebärfähigen Alter

CID 6096 (Pregnancy Status)

3 CONTAINS TEXT EV (121109, DCM, “Indications for Procedure”)

1 M

4 CONTAINS PNAME EV(1000, 99NAR, “ Physician Responsible for Indication”

1 M

5 CONTAINS CODE??? EV(1002, 99NAR, Radioactive Substance Administered”)

1 M

6 CONTAINS PNAME EV (1001, 99NAR,"Performing Person")

1 M


Examination Template

NL

Rel with Parent


1 CONTAINS TEXT EV (1004, 99NAR, ” Performing Person’s Organization Name”)

1 M Defaults to Institution Name(0008,0080)

2 CONTAINS TEXT EV (123014, DCM, “Target Region“)

1 M Free text

3 CONTAINS TEXT EV (121064, DCM, “Current Procedure Descriptions”)

1 M

4 > CONTAINS DATE EV (111060, DCM, ”Study Date”)

1 M Defaults to Study Date (0008,0020)

5 > CONTAINS TIME DV (111061, DCM, ”Study Time”)

1 U Defaults to Study Time (0008,0030)

6 CONTAINS UIDREF EV (110180, DCM, “Study Instance UID”)

U


Medical Content Template

NL

Rel with Parent


1 CONTAINS TEXT EV (121060, DCM, “History”)

1 M

2 CONTAINS TEXT EV (121062, DCM, “Request”)

1 M

3 CONTAINS TEXT EV (121071, DCM, “Finding”)

1 U

4 CONTAINS TEXT EV (121073, DCM, “Impression”)

1 M

5 CONTAINS TEXT EV (121075, DCM, “Recommendation”)

1 U


Codes

Coding Scheme Designator

Coding Scheme Version

Code Value

Code MeaningEnglish Language

Code MeaningGerman Language

LN 115287 Radiology Report Radiologischer Befundbericht

DCM 121066 Prior Procedure Descriptions Frühere Untersuchungen

DCM 111532 Pregnancy Status Schwangerschaft

DCM 121109 Indications for Procedure Rechtfertigende Indikation

99NAR 1000 Physician Responsible for Indication

Indikationsstellender Arzt

99NAR 1001 Performing Person Durchführende Person

99NAR 1004 Performing Person’s Organization Name

Institution in der die Untersuchung durchgeführt wurde

DCM 123014 Target Region Körperregion

99NAR 1002 Radioactive Substance Administered

Verabreichter radioaktiver Stoff

99NAR 1003 Radiation Exposure Strahlenexposition

DCM 121064 Current Procedure Descriptions Untersuchungstechnik

DCM 111060 Study Date Datum der Untersuchung

DCM 111061 Study Time Zeitpunkt der Untersuchung

DCM 110180 Study Instance UID Study Instance UID

DCM 121060 History Klinische Angaben

DCM 121062 Request Fragestellung

DCM 121071 Finding Beschreibung

DCM 121073 Impression Wertung

DCM 121075 Recommendation Empfehlung

helios klinikum wuppertal rsna 2006

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