HL7 Cross Paradigm IG: Gender Harmony - Sex and Gender Representation
1.0.0-ballot - ballot
HL7 Cross Paradigm IG: Gender Harmony - Sex and Gender Representation
1.0.0-ballot - ballot
This page is part of the HL7 Cross Paradigm IG: Gender Harmony - Sex and Gender Representation (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR v5.0.0-ballot. . For a full list of available versions, see the Directory of published versions 
This example was constructed to illustrate the DICOM use case.
The patient is a transgender male, undergoing hormonal treatment. Based on physician instructions, affirmed gender creatinine reference ranges were confirmed to be within normal values prior to the administration of non-ionic iodinated contrast agent. CT images for attenuation correction and anatomic localization followed by PET images were obtained.
The Social History Section includes instance examples of the Gender Identity, Pronouns, and Recorded Sex or Gender templates.
Examples of the use of the Sex for Clinical Use template can be found in the Imaging Procedure History Section.
<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Sex for Clinical Use CDA Template Example file
Version: 1.0
Revision History:
31-Jan-2011 source document created
10-Aug-2022 example drafted [Jay Lyle, JP Systems for the VHA;
Rob Horn, Fairhaven Technology;
Steven Nichols, GE]
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3"
xmlns:mif="urn:hl7-org:v3/mif" xmlns:voc="urn:hl7-org:v3/voc"
xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
<!--
********************************************************
CDA Header
********************************************************
-->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- Diagnostic Imaging Report Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.5"/>
<id root="2.16.840.1.113883.19.4.27" extension="20060828170821659"/>
<code code="18748-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Diagnostic Imaging Report"/>
<title>PET/CT Heart W contrast IV</title>
<effectiveTime value="20050329171504+0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<setId extension="111199021" root="2.16.840.1.113883.19"/>
<versionNumber value="1"/>
<recordTarget>
<!--NEW CONF per base CDA - patientRole SHALL be present of [1..*]-->
<patientRole>
<id extension="12345" root="2.16.840.1.113883.19.5"/>
<addr use="HP">
<streetAddressLine>3300 Washtenaw Ave # 227</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(734)555-1212" use="HP"/>
<patient>
<name use="L">
<given>Smith</given>
<family>John</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19541125"/>
<maritalStatusCode code="S" displayName="Single" codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode code="1013" displayName="Christian"
codeSystemName="HL7 Religious Affiliation "
codeSystem="2.16.840.1.113883.5.1076"/>
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="GRFTH" displayName="Grandfather"
codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/>
<addr use="HP">
<streetAddressLine>3300 Washtenaw Ave # 227</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(734)555-1212" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Relative</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="fr-CN"/>
<modeCode code="RWR" displayName="Recieve Written"
codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Imaging Clinic</name>
<telecom value="tel:(734)555-1212"/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Bill</given>
<family>Roentgen</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.19.5" extension="43252"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Bill</given>
<family>Roentgen</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Imaging Clinic</name>
<telecom value="tel:(555)555-1212" use="WP"/>
<addr use="HP">
<streetAddressLine>3300 Washtenaw Ave # 227</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Bill</given>
<family>Roentgen</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Good Imaging Clinic</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Bill</given>
<family>Roentgen</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>48104</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Bill</given>
<family>Roentgen</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<inFulfillmentOf>
<order>
<id extension="10523475" root="1.2.840.113619.2.62.994044785528.27"/>
<code code="121022" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="Accession Number"/>
</order>
</inFulfillmentOf>
<documentationOf>
<serviceEvent classCode="ACT">
<id root="1.2.840.113619.2.62.994044785528.114289542805"/>
<!-- study instance UID -->
<code code="78814"
displayName="Positron emission tomography (PET) with concurrently acquired computed tomography (CT)"
codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/>
<effectiveTime value="20060823222400"/>
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.10.20.6.2.1"/>
<assignedEntity>
<id extension="121008" root="2.16.840.1.113883.19.5"/>
<code code="2085R0202X" codeSystem="2.16.840.1.113883.11.19465"
codeSystemName="NUCC" displayName="Diagnostic Radiology"/>
<addr nullFlavor="NI"/>
<telecom nullFlavor="NI"/>
<assignedPerson>
<name>
<given>Matt</given>
<family>Cure</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<relatedDocument typeCode="XFRM">
<parentDocument>
<id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9"/>
<!-- SOP Instance UID (0008,0018) -->
</parentDocument>
</relatedDocument>
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="1.3.6.4.1.4.1.2835.12"/>
<effectiveTime value="20060828170821"/>
<encounterParticipant typeCode="ATND">
<templateId root="2.16.840.1.113883.10.20.6.2.2"/>
<assignedEntity>
<id extension="4" root="2.16.840.1.113883.19"/>
<code code="208D00000X" codeSystem="2.16.840.1.113883.11.19465"
codeSystemName="NUCC" displayName="General Practice"/>
<addr nullFlavor="NI"/>
<telecom nullFlavor="NI"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Fay</given>
<family>Family</family>
</name>
</assignedPerson>
</assignedEntity>
</encounterParticipant>
</encompassingEncounter>
</componentOf>
<component>
<structuredBody>
<component>
<!--
**********************************************************************
DICOM Object Catalog Section
**********************************************************************
-->
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.1.1"/>
<code code="121181" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="DICOM Object Catalog"/>
<entry>
<!--
**********************************************************************
Study
**********************************************************************
-->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.6"/>
<id root="1.2.840.113619.2.62.994044785528.114289542805"/>
<code code="113014" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="Study"/>
<!--
*****************************************************************
Series and SopInstance UID removed for brevity
*****************************************************************
-->
</act>
</entry>
</section>
<!--
**********************************************************************
End of DICOM Object Catalog Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
Social History Section
**********************************************************************
-->
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Social History</title>
<text> The patient was born female, identifes as male and is currently
undergoing gender affirming hormone therapy. <table border="1" width="100%"
cellpadding="0" cellspacing="0">
<thead>
<tr>
<th>Obs</th>
<th>Value</th>
<th>Kind</th>
<th>Jurisdiction</th>
<th>Date Acquired</th>
</tr>
</thead>
<tbody>
<tr>
<td>Gender Identity</td>
<td>Identifies as male gender</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td>Pronouns</td>
<td>He, Him, His, Himself</td>
<td/>
<td/>
<td/>
</tr>
<tr>
<td>Recorded Sex or Gender</td>
<td>Female</td>
<td>Sex Assigned at Birth</td>
<td>California</td>
<td>201201011450+0600</td>
</tr>
</tbody>
</table>
</text>
<entry>
<!-- Gender Identity -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.15.1" extension="2022-09-01"/>
<code code="76691-5" codeSystem="2.16.840.1.113883.6.1"
displayName="Gender Identity"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" code="446151000124109"
displayName="Identifies as male gender"> </value>
</observation>
</entry>
<entry>
<!-- Pronouns -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.15.2" extension="2022-09-01"/>
<code code="90778-2" codeSystem="2.16.840.1.113883.6.1"
displayName="Personal pronouns"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" code="LA29518-0"
displayName="He, Him, His, Himself"/>
</observation>
</entry>
<entry>
<!-- Recorded Sex or Gender -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.15.4" extension="2022-09-01"/>
<code code="99502-7" codeSystem="2.16.840.1.113883.6.1"
displayName="Recorded sex or gender"/>
<derivationExpr>Enter whether the infant is male, female, or if the sex
of the infant is ambiguous, enter “unknown.”</derivationExpr>
<statusCode code="completed"/>
<value xsi:type="CD" code="F">
<translation code="F" codeSystem="2.16.840.1.113883.11.19756"
codeSystemName="International Civil Aviation Organization Sex or Gender"
displayName="Female"/>
</value>
<entryRelationship typeCode="COMP">
<!-- Jurisdiction -->
<observation classCode="OBS" moodCode="EVN">
<code code="77969-4" codeSystem="2.16.840.1.113883.6.1"
displayName="Jurisdiction code"/>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="OTH" codeSystem="NP">
<!-- This may be coded but does not have to be -->
<originalText>California</originalText>
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<!-- Document Type -->
<observation classCode="OBS" moodCode="EVN">
<code code="92183-3" codeSystem="2.16.840.1.113883.6.1"
displayName="Document type"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" code="71230-7"
displayName="Birth Certificate"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<!-- Date of Entry -->
<observation classCode="OBS" moodCode="EVN">
<code code="50786-3" codeSystem="2.16.840.1.113883.6.1"
displayName="Date of entry"/>
<statusCode code="completed"/>
<value xsi:type="TS" value="201201011450+0600"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
<!--
**********************************************************************
End of Social History Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
Reason for study Section
**********************************************************************
-->
<section>
<code code="121109" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="Indications for Procedure"/>
<title>Indications for Procedure</title>
<text>Discordant clinical, ECG, and myocardial perfusion SPECT results</text>
</section>
<!--
**********************************************************************
End of Reason for study Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
History Section
**********************************************************************
-->
<section>
<code code="11329-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History"/>
<title>History</title>
<text>
<paragraph>
<caption>History</caption>
<content ID="Fndng1">History goes here...</content>
</paragraph>
</text>
<entry>
<!-- History report element (TEXT) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.12"/>
<code code="121060" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="History"/>
<value xsi:type="ED"> History text </value>
</observation>
</entry>
<!-- ***************************************************************************
Supporting information for Sex for Clinical Use
This is not likely to appear in a PET/CT report
but is provided to illustrate the use of the
supporting reference.
*****************************************************************************-->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"
extension="2014-06-09"/>
<id root="6C844C75-AA34-411C-B7BD-5E4A9F206E29"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20120318"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"
extension="2014-06-09"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code code="403922"
displayName="168 HR estradiol 0.00156 MG/HR Transdermal System"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
**********************************************************************
End of History Section
**********************************************************************
-->
<!--
**********************************************************************
Imaging Procedure Description Section
**********************************************************************
-->
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="1.2.840.10008.9.3"/>
<id root="1.2.840.10213.2.62.9940434234785528.11428954534542805"/>
<code code="55111-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Current Imaging Procedure Description"/>
<title>Imaging Procedure Description</title>
<text>
<table border="1" width="100%" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td>Sex For Clinical Use</td>
<td>Female</td>
</tr>
<tr>
<td>Imaging Technique</td>
<td>The patient is a transgender male, undergoing hormonal
treatment. Based on physician instructions, affirmed gender
creatinine reference ranges were confirmed to be within
normal values prior to the administration of non-ionic
iodinated contrast agent.. CT images for attenuation
correction and anatomic localization followed by PET images
were obtained..</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<id root="1.2.840.10213.2.62.7044785528.999999999"/>
<code code="78814"
displayName="Positron emission tomography (PET) with concurrently acquired
computed tomography (CT)"
codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.15.3"
extension="2022-09-01"/>
<code code="99501-9" codeSystem="2.16.840.1.113883.6.1"
displayName="Sex for clinical use"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.4.642.1.983"
codeSystemName="Sex For Clinical Use" code="female"
displayName="Female sex for clinical use"> </value>
<!--
*********************************************************************
Supporting Reference for Sex for Clinical Use -
This is not likely to appear in a PET/CT report
but is provided to illustrate the use of the
supporting reference.
*********************************************************************
-->
<entryRelationship typeCode="SPRT">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.122"/>
<id root="6C844C75-AA34-411C-B7BD-5E4A9F206E29"/>
<code nullFlavor="OTH" codeSystem="NP"/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</observation>
</entryRelationship>
</procedure>
</entry>
</section>
</component>
<!--
**********************************************************************
End of Imaging Procedure Description Section
**********************************************************************
-->
<component>
<!--
**********************************************************************
Findings Section
**********************************************************************
-->
<!--
**********************************************************************
SUV value - Radiologist determines relevant sex at time of
measurement and adds as DICOM acquisition context
**********************************************************************
-->
<section>
<templateId root="2.16.840.1.113883.10.20.6.1.2"/>
<code code="121070" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="Findings"/>
<title>Findings</title>
<text>
<paragraph>
<caption>Finding</caption>
<content ID="Fndng2">Findings narritive goes here...</content>
</paragraph>
<paragraph>
<caption>Standardized uptake value</caption>
<content ID="Suv2">12g/ml{SUVlbm}</content>
</paragraph>
<paragraph>
<caption>Source of Measurement</caption>
<content ID="SrceOfMeas2">
<linkHtml
href="http://www.example.org/radiology1.2.840.113619.2.62.994044785528.114289542805/series/1.2.250.1.59.40211.789001276.14556172.67789/instances/1.2.250.1.59.40211.2678810.87991027.899772.2;contentType=application/dicom"
>Coronal</linkHtml>
</content>
</paragraph>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- Text Observation -->
<templateId root="2.16.840.1.113883.10.20.6.2.12"/>
<code code="121071" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="Finding"/>
<value xsi:type="ED">
<reference value="#Fndng2"/>
</value>
<!-- inferred from measurement -->
<entryRelationship typeCode="SPRT">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.14"/>
<code code="52988006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED" displayName="Lesion">
<originalText>
<reference value="#Suv2"/>
</originalText>
</code>
<!-- no DICOM attribute -->
<statusCode code="completed"/>
<effectiveTime value="20060823223912"/>
<value xsi:type="PQ" value="12" unit="g/ml{SUVlbm}">
<translation code="g/ml{SUVlbm}"
codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"
codeSystemVersion="1.5"/>
</value>
<!-- ***********************************************************************************
Second SFCU observation to support SUV interpretation
************************************************************************************** -->
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.15.3"
extension="2022-09-01"/>
<code code="99501-9" codeSystem="2.16.840.1.113883.6.1"
displayName="Sex for clinical use"/>
<statusCode code="completed"/>
<value xsi:type="CD"
codeSystem="2.16.840.1.113883.4.642.1.983"
codeSystemName="Sex For Clinical Use" code="male"
displayName="Male sex for clinical use"> </value>
</observation>
</entryRelationship>
<!-- inferred from image -->
<entryRelationship typeCode="SUBJ">
<observation classCode="DGIMG" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.8"/>
<!-- (0008,1155) Referenced SOP Instance UID-->
<id
root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3"/>
<!-- (0008,1150) Referenced SOP Class UID -->
<code code="1.2.840.10008.5.1.4.1.1.128"
codeSystem="1.2.840.10008.2.6.1"
codeSystemName="DCMUID"
displayName="Positron Emission Tomography Image Storage"> </code>
<text mediaType="application/dicom">
<!-- reference to PET DICOM image -->
<reference
value="http://www.example.org/radiology1.2.840.113619.2.62.994044785528.114289542805/series/1.2.250.1.59.40211.789001276.14556172.67789/instances/1.2.250.1.59.40211.2678810.87991027.899772.2;contentType=application/dicom"
/>
</text>
<effectiveTime value="20060823223232"/>
<!-- Referenced Frames -->
<entryRelationship typeCode="COMP">
<observation classCode="ROIBND" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.10"/>
<code code="121190"
codeSystem="1.2.840.10008.2.16.4"
displayName="Referenced Frames"/>
<entryRelationship typeCode="COMP">
<!-- Boundary Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.11"/>
<code code="113036"
codeSystem="1.2.840.10008.2.16.4"
displayName="Group of Frames for Display"/>
<value xsi:type="INT" value="1"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<!-- Purpose of Reference -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.6.2.9"/>
<code code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value xsi:type="CD" code="121112"
codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM"
displayName="Source of Measurement">
<originalText>
<reference value="#SrceOfMeas2"/>
</originalText>
</value>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
<!--
**********************************************************************
End of Findings Section
**********************************************************************
-->
</component>
<component>
<!--
**********************************************************************
Impressions Section
**********************************************************************
-->
<section>
<code code="121072" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM"
displayName="Impressions"/>
<title>Impressions</title>
<text>
<paragraph>
<caption>Impression</caption>
<content ID="Fndng3">Impression goes here...</content>
</paragraph>
</text>
<entry>
<!-- Impression report element (TEXT) -->
<observation classCode="OBS" moodCode="EVN">
<!-- Text Observation -->
<templateId root="2.16.840.1.113883.10.20.6.2.12"/>
<code code="121073" codeSystem="1.2.840.10008.2.16.4"
codeSystemName="DCM" displayName="Impression"/>
<value xsi:type="ED">
<reference value="#Fndng3"/>
</value>
</observation>
</entry>
<entry>
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.6.2.5"/>
<!-- Procedure Context template -->
<code code="78814"
displayName="Positron emission tomography (PET) with concurrently acquired computed tomography (CT)"
codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/>
<!-- Note: This code is slightly different than the code used in the header documentationOf and overrides it, which is what this entry is for. -->
<effectiveTime value="20060823222400"/>
</act>
</entry>
</section>
<!--
**********************************************************************
End of Impressions Section
**********************************************************************
-->
</component>
</structuredBody>
</component>
</ClinicalDocument>
IG © 2022+ Example Publisher. Package hl7.xprod.uv.gender-harmony#1.0.0-ballot based on FHIR 5.0.0-ballot. Generated 2022-09-14
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