Align Document Status Information with DICOM SR

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Submitted by: <<Helmut Koenig>>	Revision date: <<Revision Date>>
Submitted date: <<October 27, 2009>>	Change request ID: <<Change Request ID>>

Issue

For communication of imaging results document status information should be harmonized between CDA and DICOM SR. DICOM has introduced a new Preliminary Flag in the SR header that indicates whether the SR document is intended to be regarded as a preliminary or final report. This is independent of the existing SR concept of "completeness" (Completion Flag) that is used to indicate whether the document contains partial or complete content.

Recommendation

• Clarify whether the CDA ClinicalDocument Status Code value "Active" (refer to Medical Records, Section 1.1.4 "Document Statuses and Transitions") matches DICOM SR Preliminary Flag value "PRELIMINARY" (DICOM Definition: "PRELIMINARY - this report precedes the final report and may contain limited information; it may be time sensitive, and it is not expected to contain all the reportable findings")
• Clarify whether the CDA ClinicalDocument Status Code value "Completed" (refer to Medical Records, Section 1.1.4 "Document Statuses and Transitions") matches DICOM SR Preliminary Flag value "FINAL" (DICOM Definition: "FINAL – this report is the definitive means of communicating the results of a procedure")
• Discuss concept of "completeness" as used by DICOM SR (completeness of content) and CDA (completeness of authentication)

in order to determine whether further harmonization is required.

Rationale

The distinction between PRELIMINARY and FINAL reports is derived from the ACR Practice Guideline For Communication Of Diagnostic Imaging Findings.

Resolution

(Resolution is to be recorded here and in the referenced minutes, which are the authoritative source of resolution).