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DICOM SR German Radiology Report

DICOM SR German Radiology Report. Thomas Hackländer. 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

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DICOM SR German Radiology Report

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  1. DICOM SRGerman Radiology Report Thomas Hackländer PD Dr. Thomas Hackländer

  2. 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 PD Dr. Thomas Hackländer

  3. 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 PD Dr. Thomas Hackländer

  4. Radiologischer Befundbericht Ebene 1 Angaben zum Patienten nach Angaben im Rahmen der Röntgenverordnung nach Angaben zur Untersuchung nach Medizinischer Inhalt nach Angaben zum Befundbericht nach Ebene 2 Name Geburtsname Geburtsdatum Geschlecht Identifikationsnummer DIN 6827-5 Radiological report • Standard was developed with DICOM SR in mind • Standard is structured into templates grouping information PD Dr. Thomas Hackländer

  5. 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 Proposal Header Elements of the Report PD Dr. Thomas Hackländer

  6. 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 Description of ProposalDICOM SR Template PD Dr. Thomas Hackländer

  7. NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 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 X-Ray Regulation Template PD Dr. Thomas Hackländer

  8. NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 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 Information concerning the Radiation Control Regulation Template PD Dr. Thomas Hackländer

  9. NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 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 Examination Template PD Dr. Thomas Hackländer

  10. NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 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 Medical Content Template PD Dr. Thomas Hackländer

  11. Coding Scheme Designator Coding Scheme Version Code Value Code MeaningEnglish Language Code MeaningGerman Language LN 11528-7 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 Codes PD Dr. Thomas Hackländer

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