Clinical Document

1. Clinical Document Patient Medical History / Relevant Prior Documents Clinical Summary Report Clinical Document HL7 Message Inclusion into * * Order Specialized Dignostics/ Interventions Image Data Post-Processing Summary/ Extract Image Data Derived Image Data Obser- vations SR -> CDA Rel.2 Transformation Evidence Document Evidence Doc Export Summary/ Extract Interpretation CCOW Access Imaging Report Export * Convey relevant information of clinical document Observations Conclusions Diagnoses HL7 CDA Imaging Report Evidence Doc Import DICOM SR On one or more Imaging procedures

2. Patient Medical History / Relevant Prior Documents Clinical Document • HL7 Order Message containing: • Reference pointer to CDA document • or • MIME encoded CDA document Departmental Information System e.g. Radiology Information System Order DIS • Discussion of different options: • MWL/GPWL: Reference Pointers to CDA Documents (Suppl.101) • Transformation of meaningful parts of the clinical document: CDA -> DICOM SR • DICOM Encapsulation of CDA and CDR (Supl.114) • DICOM Encapsulation of PDF Documents (Supl.104) Modality/ Workstation