Version 1.0

Effective date:

Jun 4, 2026

Reading physician essentials

Saving Image Edits and Presentation States - User Guide

Overview

The PACS Viewer supports saving image edits and annotations as DICOM Grayscale Softcopy Presentation States (GSPS). When saved, these Presentation States persist across sessions and can be viewed by other users who open the same exam. 

Image edits that can be saved include: 

  • Annotations and measurements 

  • Window Width / Window Level (WW/WL) 

  • Zoom and pan 

Saving behavior is governed by two things working together: 

  • The ACL permission assigned to the user's role — controls whether saving is possible at all 

  • The Hanging Protocol (HP) preference — controls whether saving happens automatically or manually (for users who have permission) 


2. Permissions — ACL Configuration 

The ACL that controls this feature is found under: 

Accounts → Role Management → Orders → Save GSPS/Annotations on System Default Viewer 

2.1 CRUD Actions 

This ACL has three CRUD actions. Each controls a distinct capability: 

Action

What it controls

Create

User can save a new Presentation State (initial save of annotations, WW/WL, zoom, pan) 

Read

User can open and view existing Presentation States saved by any user for that exam 

Update

User can save an updated Presentation State. A new GSPS object is created reflecting changes; prior PS objects are preserved and remain accessible 

⚠ Per the DICOM standard, GSPS objects cannot be physically deleted once stored. Omitting an annotation from a new save effectively removes it from view, but the prior Presentation State (with the annotation) remains accessible. The current delete option does not have any purpose. A future enhancement to the feature will disable the “delete” permission option. 

2.2 Effect of ACL on UI 

The ACL state directly determines what the user sees in both the Hanging Protocol modal and the viewer: 

ACL State

HP 'Save Image Edits' Section 

Viewer Save Button 

Can View Presentation States 

No permissions (all off) 

Hidden 

Hidden 

No

Read only 

Hidden 

Hidden 

Yes — can open and browse existing PS 

Create and/or Update enabled 

Visible and configurable

Visible 

Yes

⚠ Known Limitation (current release): If a user's Create/Update ACL is disabled, the 'Save Image Edits' toggle in the Hanging Protocol modal may still appear visible in some configurations. The toggle is non-functional in this state — no Presentation State will be created — but the UI does not currently reflect the disabled permission. This will be corrected in a future release. 

3. Hanging Protocol Preference — Save Image Edits 

For users who have Create or Update permission, the Hanging Protocol (HP) configuration controls whether image edits are saved automatically or manually. 

To access this setting, open a hanging protocol and select Save image edits under General Display and Interactions: 

3.1 Yes (Always Auto-Save) 

When Yes is selected, image edits (zoom, pan, window width, level) and annotations are automatically saved for unread exams when the exam display is closed by any of the following actions: 

  • Return to exam list 

  • Sign and close 

3.2 No 

When No is selected, image edits and annotations are not automatically saved. However, they may still be manually saved by the user. 

4. Manual Save — Presentation States 

Users with Create or Update permission who are configured for manual saving (or who wish to save mid-session) can save a Presentation State directly from the viewer. 

4.1 How to Manually Save 


  1. In the viewer, click the three-line menu (⋮) in the top-left corner of the viewport, to the left of patient name. 

  2. Select Presentation states from the menu. 

  3. In the Available Presentation States panel, click Save current presentation state. 



5. Viewing Presentation States 

All users with at least Read permission can view Presentation States saved by any user for an exam. 

5.1 How Presentation States Work — Additive Model 

Presentation States are additive. Each time a user saves, they are adding to the existing set of annotations — not replacing them. The most recent Presentation State therefore represents a cumulative summary of all annotations made across all sessions.


For example: if a radiologist adds two length measurements in one session and saves, then opens the exam again and adds an ROI annotation and saves again, the second Presentation State will contain all three annotations — both measurements plus the ROI. 

⚠ Each save creates a new GSPS object. Prior Presentation States remain accessible and can be selected individually to see annotations as they existed at any point in time. 

5.2 Default Display Behavior 

When one or more Presentation States exist for displayed images, the most recent Presentation State is applied automatically by default when the exam is opened. Because saves are additive, this means the most complete set of annotations is shown by default. 


WW/WL: If multiple Presentation States have different WW/WL values for the same image or series, the most recent value is applied. 

5.3 Hiding Presentation States and Annotations 

Two separate controls are available to hide saved content without deleting it: 

  • Hide Presentation States — hides all saved Presentation States from view. The underlying GSPS objects are not affected and will reappear when toggled back on. 

  • Hide User Annotations — hides annotations specifically. This is a separate toggle from hiding the full Presentation State, allowing users to view WW/WL and display area changes without showing annotation overlays. 

These controls allow users to review the native images without any saved overlays, and then restore them as needed.