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HELIOS Klinikum Wuppertal Department of RadiologyRSNA 2006PD Dr. Thomas Hackländer DICOM SR German Radiology Report Thomas Hackländer.

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Presentation on theme: "HELIOS Klinikum Wuppertal Department of RadiologyRSNA 2006PD Dr. Thomas Hackländer DICOM SR German Radiology Report Thomas Hackländer."— Presentation transcript:

1 HELIOS Klinikum Wuppertal Department of RadiologyRSNA 2006PD Dr. Thomas Hackländer DICOM SR German Radiology Report Thomas Hackländer

2 Department of RadologyRSNA 2006PD Dr. 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 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

3 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer 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

4 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer DIN 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 nach Angaben zur Untersuchung nach Medizinischer Inhalt nach Angaben zum Befundbericht nach NameGeburtsnameGeburtsdatumGeschlechtIdentifikationsnummer Ebene 1 Ebene 2

5 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Description of Proposal Header Elements of the Report Referenced IOD ModuleAttribute NameTagVRType PS C Patient ModulePatient's Name(0010,0010)PN2 PS C Patient ModuleOther Patient Names(0010,1001)PN3 PS C Patient ModulePatient's Birth Date(0010,0030)DA2 PS C Patient ModulePatient's Sex(0010,0040)CS2 PS C Patient ModulePatient ID(0010,0020)LO2 PS C General Study ModuleStudy Date(0008,0020)DA2 PS C General Study ModuleStudy Time(0008,0030)TM2 PS C General Study ModuleReferring Physician's Name(0008,0090)PN2 PS C General Study ModuleReferring Physician Identification Sequence (0008,0096)SQ3 PS C SR Document General ModuleAuthor Observer Sequence(0040,A078)SQ3 PS C SR Document General ModuleVerification Flag(0040,A493)CS1 PS C SR Document General ModuleVerifying Observer Sequence(0040,A073)SQ1C PS C SR Document General Module>Verifying Observer Name(0040,A075)PN1 PS C SR Document General Module>Verifying Observer Identification Code Sequence (0040,A088)SQ2 PS C SR Document General Module>Verifying Organization(0040,A027)LO1 PS C SR Document General Module>Verification DateTime(0040,A030)DT1

6 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Description of Proposal DICOM SR Template NLNL Rel with Parent Value TypeConcept NameVMRQConditionValue Set Constraint 1 CONTAINEREV ( , LN, Radiology Report) 1M Root node 2>HAS CONCEPT MOD INCLUDEDTID(1204) Language of Content Item and Descendants 1M 3>HAS OBS CONTEXT INCLUDE DTID(1001) Observation Context 1M 4> INCLUDEDTID (xx03) Information concerning the X- Ray Regulation 1UCXOR Row 5 5> INCLUDEDTID (xx04) Information concerning the Radiation Control Regulation 1UCXOR Row 4 6> INCLUDEDTID (xx05) Examination 1M 7> INCLUDEDTID (xx06) Medical Content 1M

7 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Information concerning the X-Ray Regulation Template NLNL Rel with Parent Value TypeConcept NameVMRQConditionValue Set Constraint 1 CONTAINSTEXTEV (121066, DCM, Prior Procedure Descriptions) 1M 2 CONTAINSCODEEV (111532, DCM, Pregnancy Status) 1MCNur bei Frauen im gebärfähigen Alter CID 6096 (Pregnancy Status) 3 CONTAINSTEXTEV (121109, DCM, Indications for Procedure) 1M 4 CONTAINSPNAMEEV(1000, 99NAR, Physician Responsible for Indication) 1M 5 CONTAINSPNAMEEV (1001, 99NAR, "Performing Person") 1M 6 CONTAINSTEXTEV(1003, 99NAR, Radiation Exposure 1M

8 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Information concerning the Radiation Control Regulation Template NLNL Rel with Parent Value TypeConcept NameVMRQConditionValue Set Constraint 1 CONTAINSTEXTEV (121066, DCM, Prior Procedure Descriptions ) 1M 2 CONTAINSCODEEV (111532, DCM, Pregnancy Status) 1MCNur bei Frauen im gebärfähigen Alter CID 6096 (Pregnancy Status) 3 CONTAINSTEXTEV (121109, DCM, Indications for Procedure) 1M 4 CONTAINSPNAMEEV(1000, 99NAR, Physician Responsible for Indication 1M 5 CONTAINSCODE???EV(1002, 99NAR, Radioactive Substance Administered) 1M 6 CONTAINSPNAMEEV (1001, 99NAR, "Performing Person") 1M

9 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Examination Template NLNL Rel with Parent Value TypeConcept NameVMRQConditionValue Set Constraint 1 CONTAINSTEXTEV (1004, 99NAR, Performing Persons Organization Name) 1M Defaults to Institution Name (0008,0080) 2 CONTAINSTEXTEV (123014, DCM, Target Region) 1M Free text 3 CONTAINSTEXTEV (121064, DCM, Current Procedure Descriptions) 1M 4>CONTAINSDATEEV (111060, DCM, Study Date) 1M Defaults to Study Date (0008,0020) 5>CONTAINSTIMEDV (111061, DCM, Study Time) 1U Defaults to Study Time (0008,0030) 6 CONTAINSUIDREFEV (110180, DCM, Study Instance UID) U

10 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Medical Content Template NLNL Rel with Parent Value TypeConcept NameVMRQConditionValue Set Constraint 1 CONTAINSTEXTEV (121060, DCM, History) 1M 2 CONTAINSTEXTEV (121062, DCM, Request) 1M 3 CONTAINSTEXTEV (121071, DCM, Finding) 1U 4 CONTAINSTEXTEV (121073, DCM, Impression) 1M 5 CONTAINSTEXTEV (121075, DCM, Re­commendation) 1U

11 Department of RadologyRSNA 2006PD Dr. Thomas Hackländer Codes Coding Scheme Designator Coding Scheme Version Code Value Code Meaning English Language Code Meaning German Language LN Radiology ReportRadiologischer Befundbericht DCM Prior Procedure DescriptionsFrühere Untersuchungen DCM Pregnancy StatusSchwangerschaft DCM Indications for ProcedureRechtfertigende Indikation 99NAR 1000Physician Responsible for Indication Indikationsstellender Arzt 99NAR 1001Performing PersonDurchführende Person 99NAR 1004Performing Persons Organization Name Institution in der die Untersuchung durchgeführt wurde DCM Target RegionKörperregion 99NAR 1002Radioactive Substance Administered Verabreichter radioaktiver Stoff 99NAR 1003Radiation ExposureStrahlenexposition DCM Current Procedure DescriptionsUntersuchungstechnik DCM Study DateDatum der Untersuchung DCM Study TimeZeitpunkt der Untersuchung DCM Study Instance UID DCM HistoryKlinische Angaben DCM RequestFragestellung DCM FindingBeschreibung DCM ImpressionWertung DCM RecommendationEmpfehlung


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