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DICOM SR German Radiology Report

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Presentation on theme: "DICOM SR German Radiology Report"— Presentation transcript:

1 DICOM SR German Radiology Report
Thomas Hackländer RSNA 2006 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 , „Recording in medical application of ionizing radiation – Part 5: Radiological report“ specifies the content of the report Translating DIN into a DICOM SR template RSNA 2006 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 Radiological report“ requires medical content and gives the option to document radiation protection content RSNA 2006 PD Dr. Thomas Hackländer

4 DIN 6827-5 Radiological report
Standard was developed with DICOM SR in mind Standard is structured into templates grouping information Radiologischer Befundbericht Angaben zum Patienten nach Angaben im Rahmen der Röntgenverordnung Angaben zur Untersuchung Medizinischer Inhalt Angaben zum Befundbericht Name Geburtsname Geburtsdatum Geschlecht Identifikationsnummer Ebene 1 Ebene 2 RSNA 2006 PD Dr. Thomas Hackländer

5 Description of Proposal Header Elements of the Report
Referenced IOD Module Attribute Name Tag VR Type PS C Patient Module Patient's Name (0010,0010) PN 2 Other Patient Names (0010,1001) 3 Patient's Birth Date (0010,0030) DA Patient's Sex (0010,0040) CS Patient ID (0010,0020) LO PS C General Study Module Study Date (0008,0020) Study Time (0008,0030) TM Referring Physician's Name (0008,0090) Referring Physician Identification Sequence (0008,0096) SQ PS C SR Document General Module Author Observer Sequence (0040,A078) Verification Flag (0040,A493) 1 Verifying Observer Sequence (0040,A073) 1C >Verifying Observer Name (0040,A075) >Verifying Observer Identification Code Sequence (0040,A088) >Verifying Organization (0040,A027) >Verification DateTime (0040,A030) DT RSNA 2006 PD Dr. Thomas Hackländer

6 Description of Proposal DICOM SR Template
NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 1 CONTAINER EV ( , LN, “Radiology Report“) M Root node 2 > HAS CONCEPT MOD INCLUDE DTID(1204) Language of Content Item and Descendants 3 HAS OBS CONTEXT DTID(1001) Observation Context 4 DTID (xx03) Information concerning the X-Ray Regulation UC XOR Row 5 5 DTID (xx04) Information concerning the Radiation Control Regulation XOR Row 4 6 DTID (xx05) Examination 7 DTID (xx06) Medical Content RSNA 2006 PD Dr. Thomas Hackländer

7 Information concerning the X-Ray Regulation Template
NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 1 CONTAINS TEXT EV (121066, DCM, “Prior Procedure Descriptions”) M 2 CODE EV (111532, DCM, “Pregnancy Status”) MC Nur bei Frauen im gebärfähigen Alter CID 6096 (Pregnancy Status) 3 EV (121109, DCM, “Indications for Procedure”) 4 PNAME EV(1000, 99NAR, “Physician Responsible for Indication”) 5 EV (1001, 99NAR, "Performing Person") 6 EV(1003, 99NAR, “Radiation Exposure “ RSNA 2006 PD Dr. Thomas Hackländer

8 Information concerning the Radiation Control Regulation Template
NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 1 CONTAINS TEXT EV (121066, DCM, “Prior Procedure Descriptions ”) M 2 CODE EV (111532, DCM, “Pregnancy Status”) MC Nur bei Frauen im gebärfähigen Alter CID 6096 (Pregnancy Status) 3 EV (121109, DCM, “Indications for Procedure”) 4 PNAME EV(1000, 99NAR, “ Physician Responsible for Indication” 5 CODE??? EV(1002, 99NAR, Radioactive Substance Administered”) 6 EV (1001, 99NAR, "Performing Person") RSNA 2006 PD Dr. Thomas Hackländer

9 Examination Template NL Rel with Parent Value Type Concept Name VM RQ
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”) M Defaults to Institution Name (0008,0080) 2 EV (123014, DCM, “Target Region“) Free text 3 EV (121064, DCM, “Current Procedure Descriptions”) 4 > DATE EV (111060, DCM, ”Study Date”) Defaults to Study Date (0008,0020) 5 TIME DV (111061, DCM, ”Study Time”) U Defaults to Study Time (0008,0030) 6 UIDREF EV (110180, DCM, “Study Instance UID”) RSNA 2006 PD Dr. Thomas Hackländer

10 Medical Content Template
NL Rel with Parent Value Type Concept Name VM RQ Condition Value Set Constraint 1 CONTAINS TEXT EV (121060, DCM, “History”) M 2 EV (121062, DCM, “Request”) 3 EV (121071, DCM, “Finding”) U 4 EV (121073, DCM, “Impression”) 5 EV (121075, DCM, “Re­commendation”) RSNA 2006 PD Dr. Thomas Hackländer

11 Codes Coding Scheme Designator Coding Scheme Version Code Value
Code Meaning English Language Code Meaning German Language LN Radiology Report Radiologischer Befundbericht DCM 121066 Prior Procedure Descriptions Frühere Untersuchungen 111532 Pregnancy Status Schwangerschaft 121109 Indications for Procedure Rechtfertigende Indikation 99NAR 1000 Physician Responsible for Indication Indikationsstellender Arzt 1001 Performing Person Durchführende Person 1004 Performing Person’s Organization Name Institution in der die Untersuchung durchgeführt wurde 123014 Target Region Körperregion 1002 Radioactive Substance Administered Verabreichter radioaktiver Stoff 1003 Radiation Exposure Strahlenexposition 121064 Current Procedure Descriptions Untersuchungstechnik 111060 Study Date Datum der Untersuchung 111061 Study Time Zeitpunkt der Untersuchung 110180 Study Instance UID 121060 History Klinische Angaben 121062 Request Fragestellung 121071 Finding Beschreibung 121073 Impression Wertung 121075 Recommendation Empfehlung RSNA 2006 PD Dr. Thomas Hackländer


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