The Medical Imaging Observation template defines the format for the results of observations generated by imaging procedures. The scope includes observations such as plain x-ray, ultrasound, CT, MRI, angiography, echocardiography and nuclear medicine observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.
Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.
The Image Procedure Code element is used to identify the specific procedure that was performed on the patient. The E2E Specification does not recommend any specific Code System to be used for this element.
If the source system does NOT contain a code for the procedure, then the Image Procedure Code element SHALL be the NullFlavor ‘OTH’ and the Image Procedure Name element SHALL be populated:
If the source system does contain a code for the procedure then the Image Procedure Code element SHALL be populated with the code, codeSystem, codeSystemName and displayName.
The receiving system SHALL support receipt of coded imaging procedure results.
If the receiving system cannot process the codeSystem for the Image procedure Code, then the receiving system SHALL capture the procedure as a free text entry and SHALL store the received code information with the record.
Context
Parent nodes of template element with id 2.16.840.1.113883.3.1818.10.3.13
Classification
CDA Entry Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 3 templates
Draft