COLON CAD SR IOD TEMPLATES

The templates that comprise the Colon CAD SR IOD are interconnected as in Figure A-9b. In Figure A-9b, ‘( ( (’ indicates possible recursive application of subordinate templates.

[pic]

Figure A-9b: Colon CAD SR IOD Template Structure

TID 4120 Colon CAD Document Root Template

This template forms the top of a content tree that allows a colon CAD device to describe the results of detection and analysis of colon evidence. This template, together with its subordinate templates, describes both the results for presentation to radiologists and partial product results for consumption by colon CAD devices in subsequent colon CAD reports.

This template defines a Container that contains the CAD results and summaries of the detection and analysis algorithms performed.

The atomic CAD results of Single Image Findings and Composite Features are described in the Colon CAD Findings Summary sub-tree.

The Summary of Detections and Summary of Analyses sub-trees gather lists of algorithms attempted, grouped by success/failure status. Algorithms not attempted are not mentioned in these sub-trees. This information forms the basis for understanding why a colon CAD report may produce no (or fewer than anticipated) results. Colon CAD results are constructed bottom-up, starting from Single Image Findings (see TID 4127), associated as Composite Features (see TID 4125).

See the figure entitled “Top Levels of Colon CAD SR Content Tree” in the “Colon CAD” Annex of PS 3.17.

TID 4120COLON CAD DOCUMENT ROOT

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER EV (112220, DCM, “Colon CAD Report”) 1 M
2 > HAS CONCEPT MOD INCLUDE DTID (1204) Language of Content Item and Descendants 1 M
3 > CONTAINS INCLUDE DTID (4122) CAD Common Image Properties Entry 1-n M
4 > CONTAINS INCLUDE DTID (4121) Colon CAD Findings Summary 1 M
5 > CONTAINS CODE EV (111064, DCM, “Summary of Detections”) 1 M DCID (6042) Status of Results
6 >> INFERRED FROM INCLUDE DTID (4015) CAD Detections Performed 1 MC Shall be present unless the value of row 5 is (111225, DCM, “Not Attempted”) $DetectionCode = DCID (6201) Colon Finding or Feature
7 > CONTAINS CODE EV (111065, DCM, “Summary of Analyses”) 1 M DCID (6042) Status of Results
8 >> INFERRED FROM INCLUDE DTID (4016) CAD Analyses Performed 1 MC Shall be present unless the value of row 7 is (111225, DCM, “Not Attempted”) $AnalysisCode = DCID (6137) Types of CAD Analysis

Content Item Descriptions

Detections Performed The “Detections Performed” and “Analyses Performed” sections of the Content Tree (TID 4120, rows 6 and 8) together shall reference all Image SOP Instances included in the Current Requested Procedure Evidence Sequence (0040,A375) attribute of the SR Document General module.
Analyses Performed

TID 4121 Colon CAD Findings Summary Template

The contents of this template describe the findings and aggregate features that the colon CAD device detected for the colon evidence presented. This template forms the colon CAD results sub-tree of the Colon CAD Document Root (TID 4120). The data from which the details are inferred are expressed in the Composite Features (see TID 4125) and/or Single Image Findings (see TID 4127), of which there may be several.

The sub-tree headed by this template is illustrated in the figure entitled “Example of CAD Processing and Findings Summary sub-tree of Colon CAD SR Content Tree” in the “Colon CAD” Annex of PS 3.17.

TID 4121COLON CAD FINDINGS SUMMARY

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (111017, DCM, “CAD Processing and Findings Summary”) 1 M DCID (6047) CAD Processing and Findings Summary
2 > HAS PROPERTIES CODE EV (112222, DCM, “Colon Overall Assessment”) 1 U DCID (6200) Colon Overall Assessment
3 > INFERRED FROM INCLUDE DTID (4125) Colon CAD Composite Feature 1-n U
4 > INFERRED FROM INCLUDE DTID (4127) Colon CAD Single Image Finding 1-n U

Content Item Descriptions

CAD Processing and Findings Summary This code value is used to express if and why the Colon CAD Findings Summary sub-tree is empty. The Summary of Detections and Summary of Analyses sub-trees of the Document Root node contain detail about which (if any) algorithms succeeded or failed. If the code value indicates that there were no findings, then the code value can be used to determine whether colon CAD processing occurred successfully, without parsing the Summary of Detections and Summary of Analyses sub-trees.

TID 4122 CAD Common Image Properties Entry Template

Each instance of the CAD Common Image Properties Entry template contains selected attributes for a set of parallel contiguous equally spaced slices (with identical properties) from which CAD findings are derived.

TID 4122 CAD COMMON IMAGE PROPERTIES ENTRYType: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER EV (112224, DCM, “Image Set Properties”) 1 M
2 > CONTAINS UIDREF EV (112227, DCM, “Frame of Reference UID”) 1 M
3 > CONTAINS UIDREF EV (110180, DCM, “Study Instance UID”) 1 M
4 > CONTAINS DATE EV (111060, DCM, “Study Date”) 1 M Shall be taken from Study Date (0008,0020) in the Image Instances.
5 > CONTAINS TIME EV (111061, DCM, “Study Time”) 1 M Shall be taken from Study Time (0008,0030) in the Image Instances.
6 > CONTAINS CODE EV (121139, DCM, “Modality”) 1 M Shall be taken from Modality (0008,0060) in the Image Instances.
7 > CONTAINS NUM EV (111026, DCM, ”Horizontal Pixel Spacing”) 1 M Shall be taken from value 1 of Pixel Spacing (0028,0030) in the Image Instances. UNITS = EV (mm/{pixel}, UCUM, “millimeters per pixel”)
8 > CONTAINS NUM EV (111066, DCM, ”Vertical Pixel Spacing”) 1 M Shall be taken from value 2 of Pixel Spacing (0028,0030) in the Image Instances. UNITS = EV (mm/{pixel}, UCUM, “millimeters per pixel”)
9 > CONTAINS NUM EV (112225, DCM, “Slice Thickness”) 1 M Shall be taken from Slice Thickness (0018,0050) in the Image Instances. UNITS = EV (mm, UCUM, “millimeter”)
10 > CONTAINS CODE EV (112226, DCM, “Spacing between slices”) 1 M Shall be computed from the Image Position (Patient) (0020,0032) projected onto the normal to the Image Orientation (Patient) (0020,0037); may or may not be the same as the Spacing Between Slices (0018,0088) if present. UNITS = EV (mm, UCUM, “millimeter”)
11 > CONTAINS CODE EV (112228, SRT, “Recumbent Patient Position with respect to gravity”) 1 MC Required if Patient Position (0018,5100) is present in the image instances and has a value. Shall be derived from Patient Position (0018,5100) in the Image Instances. DCID (6206) Recumbent Patient Orientation for Colon CAD

TID 4125 Colon CAD Composite Feature Template

This template collects a composite feature for a lesion, non-lesion object, or correlation of related objects (see TID 4121). The details of the composition are expressed in the Colon CAD Composite Feature Body (see TID 4126). The data from which the details are inferred, are expressed in the Composite Features (see TID 4125) and/or Single Image Findings (see TID 4127), of which there may be several.

TID 4125COLON CAD COMPOSITE FEATURE

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (111015, DCM, “Composite Feature”) 1 M DCID (6201) Colon Finding or Feature
2 > HAS CONCEPT MOD CODE EV (112023, DCM, “Composite Feature Modifier”) 1 U DCID (6202) Colon Finding or Feature Modifier
3 > HAS CONCEPT MOD CODE EV (111056, DCM, “Rendering Intent”) 1 M DCID (6034) Intended Use of CAD Output
4 >> HAS PROPERTIES NUM EV (111071, DCM, “CAD Operating Point”) 1 UC IFF value of row 3 is (111151, DCM, “Presentation Optional”) and row 1 of TID 4023 is present for the feature identified in row 1. UNITS = DT ({1:n}, UCUM, “range: 1:n”), where n is the maximum specified in Row 1 of TID 4023 for the feature identified in row 1. Value is restricted to being an integer.
5 > HAS OBS CONTEXT INCLUDE DTID (4108) Tracking Identifier 1 U
6 > HAS OBS CONTEXT INCLUDE DTID (4022) CAD Observation Context 1 MC Shall be present IFF this feature is duplicated from a different report than its parent.
7 > HAS OBS CONTEXT INCLUDE DTID (4019) CAD Algorithm Identification 1 M
8 > HAS PROPERTIES INCLUDE DTID (4126) Colon CAD Composite Feature Body 1 M
9 > INFERRED FROM INCLUDE DTID (4125) Colon CAD Composite Feature 1-n U
10 > INFERRED FROM INCLUDE DTID (4127) Colon CAD Single Image Finding 1-n U

Content Item Descriptions

Rendering Intent This content item constrains the SCP receiving the Colon CAD SR IOD in its use of the contents of this template and its target content items. Colon CAD devices may opt to use data marked “Not for Presentation” or “Presentation Optional” as input to subsequent colon CAD processing steps. Refer to PS 3.4, Annex O Structured Reporting Standard SOP Classes for SCU and SCP Behavior.

TID 4126 Colon CAD Composite Feature Body Template

The details of a composite feature are expressed in this template. It is applied to Colon CAD Composite Feature (TID 4125).

TID 4126COLON CAD COMPOSITE FEATURE BODY

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (111016, DCM, “Composite type”) 1 M DCID (6035) Composite Feature Relations
2 CODE EV (111057, DCM, “Scope of Feature”) 1 M DCID (6036) Scope of Feature
3 NUM EV (111011, DCM, “Certainty of feature”) 1 U UNITS = EV (%, UCUM, “Percent”) Value = 0 – 100
4 INCLUDE DTID (4129) Colon CAD Geometry 1 U
5 INCLUDE DTID (4128) Colon CAD Descriptors 1 U
6 NUM DCID (6207) Colon Quantitative Temporal Difference Type 1-n UC May be present IFF the value of row 1 is (111153, DCM, “Target content items are related temporally”)
7 > R-INFERRED FROM NUM 2 U The referenced numeric values shall have the same Concept Name. Their UNITS shall be the same as row 6
8 CODE EV (111049, DCM, “Qualitative Difference”) 1-n UC May be present only if the value of row 1 is (111153, DCM, “Target content items are related temporally”) DCID (6134) Qualitative Temporal Difference Type
9 > HAS PROPERTIES TEXT EV (111021, DCM, “Description of Change”) 1 U
10 > R-INFERRED FROM CODE 2 M The referenced content items shall have the same Concept Name and their code values shall be from the same context group.

Content Item Descriptions

Certainty of Feature The CAD device’s certainty that the feature analyzed and classified by the CODE, as specified in the Composite Feature parent template is, in fact, that type of feature.
Row 6 Values ( 0 are allowed. The two referenced numeric values are target content items of the first generation Composite Feature or Single Image Finding children of this composite feature. Given the equation, A – B, the value representing A shall be referenced first.
Qualitative Difference The two referenced code values are target content items of the first generation Composite Feature or Single Image Finding children of this composite feature.

TID 4127 Colon CAD Single Image Finding Template

This template describes a single image finding for a lesion or other object. The details of the finding are expressed in this template and/or more specific templates.

TID 4127COLON CAD SINGLE IMAGE FINDING

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (111059, DCM, “Single Image Finding”) 1 M DCID (6201) Colon Finding or Feature
2 > HAS CONCEPT MOD CODE EV (112024, DCM, “Single Image Finding Modifier”) 1 U DCID (6202) Colon Finding or Feature Modifier
3 > HAS CONCEPT MOD CODE EV (111056, DCM, “Rendering Intent”) 1 M DCID (6034) Intended Use of CAD Output
4 >> HAS PROPERTIES NUM EV (111071, DCM, “CAD Operating Point”) 1 UC IFF value of row 3 is (111151, DCM, “Presentation Optional”) and row 1 of TID 4023 is present for the finding identified in row 1 UNITS = DT ({1:n}, UCUM, “range: 1:n”), where n is the maximum specified in Row 1 of TID 4023 for the finding identified in row 1. Value is restricted to being an integer.
5 > HAS OBS CONTEXT INCLUDE DTID (4108) Tracking Identifier 1 U
6 > HAS OBS CONTEXT INCLUDE DTID (4022) CAD Observation Context 1 MC Shall be present IFF this finding is duplicated from a different report than its parent.
7 > HAS OBS CONTEXT INCLUDE DTID (4019) CAD Algorithm Identification 1 M
8 > HAS PROPERTIES NUM EV (111012, DCM, “Certainty of Finding”) 1 U UNITS = EV (%, UCUM, “Percent”) Value = 0 – 100
9 > HAS PROPERTIES TEXT EV (111058, DCM, “Selected Region Description”) 1 MC Shall be present IFF value of row 1 is (111099, DCM, “Selected region”)
10 > HAS PROPERTIES INCLUDE DTID (4129) Colon CAD Geometry 1 MC Shall be present unless value of row 1 is (111101, DCM, “Image quality”)
11 > HAS PROPERTIES INCLUDE DTID (4128) Colon CAD Descriptors 1 U
12 > INFERRED FROM IMAGE 1 MC Shall be present IFF value of row 1 is (111101, DCM, “Image quality”) and row 13 is not present
13 > INFERRED FROM SCOORD EV (111030, DCM, “Image Region”) 1-n MC Shall be present IFF value of row 1 is (111101, DCM, “Image quality”) and row 12 is not present
14 >> SELECTED FROM IMAGE 1 M All the row 13 content items in a single invocation of this template shall reference the same IMAGE
15 > HAS PROPERTIES INCLUDE DTID (4014) CAD Image Quality 1 MC Shall be present IFF value of row 1 is (111101, DCM, “Image quality”) $QualityFinding = DCID (6135) Image Quality Finding $QualityStandard = DCID (6208) Colon Types of Quality Control Standard

Content Item Descriptions

Rendering Intent This content item constrains the SCP receiving the Colon CAD SR IOD in its use of the contents of this template and its target content items. Colon CAD devices may opt to use data marked “Not for Presentation” or “Presentation Optional” as input to subsequent colon CAD processing steps. Refer to PS 3.4 section on Structured Reporting Storage SOP Classes for SCU and SCP Behavior.
CAD Operating Point Additional information to use when Rendering Intent is “Presentational Optional”. A CAD Operating Point of zero is not sent, and is encoded as a Rendering Intent of “Presentation Required”. See PS 3.4 section on Structured Reporting Storage SOP Classes for SCU and SCP Behavior and PS 3.17 annex on Mammography.
Certainty of Finding The certainty of the CAD device that the finding detected and classified by the Single Image Finding CODE specified is in fact that type of finding.

TID 4128 Colon CAD Descriptors

This template provides qualitative detail for a Single Image Finding or Composite Feature. It is applied to Colon CAD Composite Feature (TID 4125) and Colon CAD Single Image Finding (TID 4127).

TID 4128COLON CAD DESCRIPTORS

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (G-C504, SRT, “Associated Morphology”) 1-n U DCID (6209) Colon Morphology Descriptor
2 CODE EV (G-C036, SRT, “Finding Site”) 1 U DCID (6210) Location in Intestinal Tract
3 CODE EV (111014, DCM, “Clockface or region”) 1 U DCID (6205) Clockface Location for Colon
4 CONTAINS INCLUDE DTID (300) Measurement 1-n U $Measurement = DCID (6212) Calculated Value for Colon Findings $Derivation = DCID (6140) Calculation Methods $DerivationParameter = EV (112032, DCM, “Threshold Attenuation Coefficient”) $DerivationParameterUnits = EV ([hnsf’U], UCUM, “Hounsfield unit”)
5 INCLUDE DTID (1400) Linear Measurement 1-n U
6 INCLUDE DTID (1401) Area Measurement 1-n U
7 INCLUDE DTID (1402) Volume Measurement 1-n U
8 INCLUDE DTID (1406) 3D Linear Measurement 1-n U
9 NUM DCID (6141) Attenuation Coefficient Measurements 1-n U UNITS = EV ([hnsf’U], UCUM, “Hounsfield unit”)
10 > HAS PROPERTIES CODE EV (112009, DCM, “Type of Content”) 1 U DCID (6211) Colon CAD Material Description

Content Item Descriptions

Row 3 12 o’clock position is the anterior direction of the patient regardless of the positioning with respect to gravity; clockwise is from the point of view of an observer located closer to the anus than the finding being observed.

TID 4129 Colon CAD Geometry Template

All geometry template invocations require specification of either the location of the center of the object, the outline, or both. Geometry is a property of single image findings (see TID 4127) and composite features (see TID 4125).

TID 4129COLON CAD GEOMETRY

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 SCOORD EV (111010, DCM, “Center”) 1 MC At least one of rows 1, 3, 4, 6 or 11 shall be present. GRAPHIC TYPE = {POINT}
2 > SELECTED FROM IMAGE 1 M
3 SCOORD3D EV (111010, DCM, “Center”) 1 MC At least one of rows 1, 3, 4, 6 or 11 shall be present. GRAPHIC TYPE = {POINT}
4 SCOORD EV (111041, DCM, “Outline”) 1 MC At least one of rows 1, 3, 4, 6 or 11 shall be present.
5 > SELECTED FROM IMAGE 1 M
6 SCOORD3D EV (111041, DCM, “Outline”) 1 MC At least one of rows 1, 3, 4, 6 or 11 shall be present.
7 SCOORD DCID (6166) CAD Geometry Secondary Graphical Representation 1-n U
8 > SELECTED FROM IMAGE 1 M
9 SCOORD3D DCID (6166) CAD Geometry Secondary Graphical Representation 1-n U
10 IMAGE EV (112229, DCM, “Identifying Segment”) 1 MC At least one of rows 1, 3, 4, 6 or 11 shall be present. Referenced image shall be a Segmentation and the content item shall include Referenced Segment Number (0062,000B)
BREAST IMAGING REPORT TEMPLATES

The templates that comprise the Breast Imaging Report are interconnected as in Figure A-10:

[pic]Figure A-10: Breast Imaging Report Template Structure

TID 4200 Breast Imaging Report

This template forms the content tree that allows a Breast Imaging Report device to describe the results of a radiologist’s diagnostic interpretation of Breast Imaging (e.g., X-Ray mammography or breast ultrasound) evidence. This template, together with its subordinate templates, describes the results for presentation to clinicians, or for consumption by Breast Imaging Report devices for subsequent Breast Imaging Reports.

This template shall be instantiated at the Root node only.

See the figure entitled “Top Levels of Breast Imaging Report Content Tree” in the “Breast Imaging Report Content Tree Structure” Annex of PS 3.17.

TID 4200 BREAST IMAGING REPORT

Type: Non-Extensible Order: Significant

NL
TID 4202 Breast Imaging Report Narrative

This template contains the narrative text sub-tree of the content tree of a Breast Imaging Report. The narrative summary may be subdivided into sections with section headings.

See the figure entitled “Breast Imaging Report Narrative Content Tree” in the “Breast Imaging Report Content Tree Structure” Annex of PS 3.17.

TID 4202 BREAST IMAGING REPORT NARRATIVE

Type: Non-Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER EV (125000, DCM, “OB-GYN Ultrasound Procedure Report”) 1 M
2 > HAS CONCEPT MOD INCLUDE DTID (1204) Language of Content Item and Descendants 1 U
3 > HAS OBS CONTEXT INCLUDE DTID (1001) Observation Context 1 M
4 > CONTAINS INCLUDE DTID (5001) Patient Characteristics 1 U
5 > CONTAINS CONTAINER DT (111028, DCM, “Image Library”) 1 U
6 >> CONTAINS IMAGE No purpose of reference 1-n M
7 > CONTAINS INCLUDE DTID (5002) OB-GYN Procedure Summary Section 1 U
8 > CONTAINS INCLUDE DTID (5004) Fetal Biometry Ratio Section 1-n U
9 > CONTAINS INCLUDE DTID (5005) Fetal Biometry Section 1-n U
10 > CONTAINS INCLUDE DTID (5006) Long Bones Section 1-n U
11 > CONTAINS INCLUDE DTID (5007) Fetal Cranium Section 1-n U
12 > CONTAINS INCLUDE DTID (5009) Fetal Biophysical Profile Section 1-n U
13 > CONTAINS INCLUDE DTID (5011) Early Gestation Section 1-n U
14 > CONTAINS INCLUDE DTID (5010) Amniotic Sac Section 1 U
15 > CONTAINS INCLUDE DTID (5015) Pelvis and Uterus Section 1 U
16 > CONTAINS INCLUDE DTID (5012) Ovaries Section 1 U
17 > CONTAINS INCLUDE DTID (5013) Follicles Section 1 U $Laterality = EV (G-A101, SRT, “Left”) $Number = EV (11879-4, LN, “Number of follicles in left ovary”)
18 > CONTAINS INCLUDE DTID (5013) Follicles Section 1 U $Laterality = EV (G-A100, SRT, “Right”) $Number = EV (11880-2, LN, “Number of follicles in right ovary”)
19 > CONTAINS CONTAINER EV (121070, DCM, “Findings”) 1-n U
20 >> HAS CONCEPT MOD CODE EV (G-C0E3, SRT, “Finding SIte”) 1 M EV (T-F6800, SRT, “Embryonic Vascular Structure”)
21 >> CONTAINS INCLUDE DTID (5025) OB-GYN Fetal Vascular Measurement Group 1 M $AnatomyGroup = DCID (12141) Fetal Vasculature
22 > CONTAINS CONTAINER EV (121070, DCM, “Findings”) 1 U
23 >> HAS CONCEPT MOD CODE EV (G-C0E3, SRT, “Finding SIte”) 1 M EV (T-D6007, SRT, “Pelvic Vascular Structure”)
24 >> CONTAINS INCLUDE DTID (5026) OB-GYN Pelvic Vascular Measurement Group 1 M $AnatomyGroup = DCID (12140) Pelvic Vasculature Anatomical Location

TID 5001 OB-GYN Patient Characteristics

Patient Characteristic concepts in this template, which may replicate attributes in the Patient Study Module, are included here as possible targets of by-reference relationships from other content items in the SR tree.

Note: Several of the concepts in this template duplicate concepts in TID 1007 “Subject Context, Patient”. The difference in use is that this template has those concepts as primary observations of the patient, while in TID 1007 the concepts are used to set (or reset) the context for other observations.

TID 5001 OB-GYN PATIENT CHARACTERISTICS Type: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER EV (121118, DCM, “Patient Characteristics”) 1 M
2 > CONTAINS TEXT EV (121106, DCM, “Comment”) 1 U
3 > CONTAINS NUM EV (8302-2, LN, “Patient Height”) 1 U
4 > CONTAINS NUM EV (29463-7, LN, “Patient Weight”) 1 U
5 > CONTAINS NUM EV (11996-6, LN, “Gravida”) 1 U
6 > CONTAINS NUM EV (11977-6, LN, “Para”) 1 U
7 > CONTAINS NUM EV (11612-9, LN, “Aborta”) 1 U
8 > CONTAINS NUM EV (33065-4, LN, “Ectopic Pregnancies”) 1 U

TID 5002 OB-GYN Procedure Summary Section

Observations of the procedure of immediate clinical interest.

TID 5002OB-GYN PROCEDURE SUMMARY SECTIONType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (121111, DCM, “Summary”) 1 M
2 > CONTAINS DATE DCID (12003) OB-GYN Dates 1-n U
3 > CONTAINS INCLUDE DTID (300) Measurement 1-n U $Measurement = BCID (12018) OB-GYN Summary
4 > CONTAINS TEXT EV (121106, DCM, “Comment”) 1-n U
5 >> INCLUDE DTID (320) Image or Spatial Coordinates 1-n U
6 > CONTAINS INCLUDE BTID (5003) OB-GYN Fetus Summary 1-n UC No more than 1 inclusion per fetus

TID 5003 OB-GYN Fetus Summary

The Fetus Summary template is a container for summary data of a fetus.

TID 5003OB-GYN PROCEDURE FETUS SUMMARYType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125008, DCM, “Fetus Summary”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS TEXT EV (121106, DCM, “Comment”) 1-n U
4 >> INCLUDE DTID (320) Image or Spatial Coordinates 1 U
5 > CONTAINS INCLUDE DTID (300) Measurement 1-n U $Measurement = DCID (12019) OB-GYN Fetus Summary $Equation = DCID (12012) OB Equations and Tables

TID 5004 Fetal Biometry Ratio Section

The Fetal Biometry Section Ratio template is a container for common biometric ratios.

TID 5004FETAL BIOMETRY RATIO SECTIONType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125001, DCM, “Fetal Biometry Ratios”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS NUM DCID (12004) Fetal Biometry Ratios 1-n M
4 >> R-INFERRED FROM NUM 2 U
5 >> HAS PROPERTIES INCLUDE DTID (312) Normal Range Properties 1 U

Content Item Descriptions

Row 3 Numeric ratio related to fetal growth
Row 4 Reference to the numerator and denominator of the ratio.

TID 5005 Fetal Biometry Section

The Fetal Biometry Section template is a container for common biometric groups.

TID 5005FETAL BIOMETRY SECTIONType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125002, DCM, ”Fetal Biometry”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS INCLUDE DTID (5008) Fetal Biometry Group 1-n M $BiometryType = MemberOf {DCID (12005) Fetal Biometry Measurements}

Content Item Descriptions

Row 3 The group of measurements. Only one group per biometry type.

TID 5006 Fetal Long Bones Section

The Long Bones template is a container for biometric data of long bones.

TID 5006FETAL LONG BONES SECTIONType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125003, DCM, ”Fetal Long Bones”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS INCLUDE DTID (5008) Fetal Biometry Group 1-n M $BiometryType = MemberOf {DCID (12006) Fetal Long Bones Biometry Measurements}

Content Item Descriptions

Row 3 The group of measurements. Only one group per biometry type.

TID 5007 Fetal Cranium Section

The Fetal Cranium template is a container for groups of biometric data of the fetal cranium.

TID 5007FETAL CRANIUM SECTIONType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125004, DCM, ”Fetal Cranium”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS INCLUDE DTID (5008) Fetal Biometry Group 1-n M $BiometryType = MemberOf {DCID (12007) Fetal Cranium}

Content Item Descriptions

Row 3 The group of measurements. Only one group per biometry type.

TID 5008 Fetal Biometry Group

The Biometry Group template is container for a biometric value and its associated growth metrics.

TID 5008 Parameters

Parameter Name Parameter Usage
$BiometryType The concept name of the biometry measurement

TID 5008 FETAL BIOMETRY GROUPType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT(125005, DCM, ”Biometry Group”) 1 M
2 > CONTAINS INCLUDE DTID (300) Measurement 1-n MC At least one of row 2 and 3 shall be present $Measurement = $BiometryType $Derivation = DCID (3627) Measurement Type
3 > CONTAINS NUM EV (18185-9, LN, ”Gestational Age”) 1 MC At least one of row 2and 3 shall be present Units= EV (d,UCUM, days)
4 >> INFERRED FROM CODE DCID (228) Equation or Table 1 U DCID (12013) Gestational Age Equations and Tables
5 >> R-INFERRED FROM NUM 1-n U
6 >> HAS PROPERTIES NUM DCID (226) Population Statistical Descriptors 1-n U
7 > CONTAINS NUM DCID (12017) Growth Distribution Rank 1 U
8 >> INFERRED FROM CODE DCID (228) Equation or Table 1 U DCID (12015) Fetal Growth Equations and Tables

Content Item Descriptions

Row 1 Container to segregate biometry data by measurement type
Row 2 The discrete measurements of the biometry type including derived measurements such as mean. One of the measurements may be flagged as selected for derived measurements.
Row 3 The estimated gestational age derived from an equation or table based on the explicitly referenced R-INFERRED FROM content item, selected measurement or mean, in that order of preference.
Row 4 The reference that defines the equation or table of GA derivation
Row 6 The uncertainty/confidence limits of the gestational age
Row 7 Expresses the rank of the selected or mean measurement of row 2 relative to the distribution specified in row 8.
Row 8 This row specifies the CODE reference used to compute the percentile or Z-score.

TID 5009 Fetal Biophysical Profile Section

This template encodes scoring observations for fetal well-being evaluation as described by Manning, Antepartum Fetal Evaluation: Development of a Fetal Biophysical Profile Score, Am. J Obsetet Gynecol, 1980;136:787.

TID 5009FETAL BIOPHYSICAL PROFILE SECTIONType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125006, DCM, ”Biophysical Profile”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS NUM EV (11631-9, LN, “Gross Body Movement”) 1 MC At least one of row 3-7 shall be present Units = DT (“{0:2}”, UCUM, ”range 0:2”)
4 > CONTAINS NUM EV (11632-7, LN, “Fetal Breathing”) 1 MC At least one of row 3-7 shall be present Units = DT (“{0:2}”, UCUM, ”range 0:2”)
5 > CONTAINS NUM EV (11635-0, LN, “Fetal Tone”) 1 MC At least one of row 3-7 shall be present Units = DT (“{0:2}”, UCUM, ”range 0:2”)
6 > CONTAINS NUM EV (11635-5, LN, “Fetal Heart Reactivity”) 1 MC At least one of row 3-7 shall be present Units = DT (“{0:2}”, UCUM, ”range 0:2”)
7 > CONTAINS NUM EV (11630-1, LN, “Amniotic Fluid Volume”) 1 MC At least one of row 3-7 shall be present Units = DT (“{0:2}”, UCUM, ”range 0:2”)
8 > CONTAINS NUM DT (11634-3, LN, “Biophysical Profile Sum Score”) 1 U

Content Item Descriptions

Row 3-7 The numeric profile score of range 0-2
Row 8 The sum of rows 3-7. The range is from 0 to the maximum possible score according the items scored in rows 3-7.

TID 5010 Amniotic Sac Section

This template specifies a container for amniotic sac quadrant diameters and a derived index.

TID 5010AMNIOTIC SAC SECTIONType: Extensible Order: Significant

NL
Row 4 The four amniotic sac quadrant diameters

TID 5011 Early Gestation Section

The Early Gestation Section template is a container for common, first trimester biometric groups.

TID 5011EARLY GESTATION SECTIONType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125009, DCM, “Early Gestation”) 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > CONTAINS INCLUDE DTID (5008) Fetal Biometry Group 1-n M $BiometryType= Member of {DCID (12009) Early Gestation Biometry Measurements}

TID 5012 Ovaries Section

This template contains metrics of ovary size.

TID 5012OVARIES SECTIONType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (121070, DCM, “Findings”) 1 M
2 > HAS CONCEPT MOD CODE EV (G-C0E3, SRT, “Finding Site”) 1 M DT (T-87000, SRT, ”Ovary”)
3 > CONTAINS INCLUDE DTID (5016) LWH Volume Group 1 U $GroupName = EV (T-87000, SRT, ”Ovary”) $Width =EV (11829-9,LN, ”Left Ovary Width”) $Length =EV (11840-6, LN, ”Left Ovary Length”) $Height =EV (11857-0 , LN,” Left Ovary Height”) $Volume=EV (12164-0, LN, ”Left Ovary Volume”)
4 > CONTAINS INCLUDE DTID (5016) LWH Volume Group 1 U $GroupName = EV (T-87000, SRT, ”Ovary”) $Width = EV (11830-7, LN, ”Right Ovary Width”) $Length = EV (11841-4, LN, ”Right Ovary Length”) $Height = EV (11858-8, LN, ”Right Ovary Height”) $Volume= EV (12165-7, LN, ”Right Ovary Volume”)

TID 5013 Follicles Section

This template contains follicle metrics for left or right ovarian follicles.

TID 5013 Parameters

Parameter Name Parameter Usage
$Laterality Ovary laterality
$Number The number of follicles

TID 5013FOLLICLES SECTIONType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (121070, DCM, “Findings”) 1 M
2 > HAS CONCEPT MOD CODE EV (G-C0E3, SRT, “Finding Site”) 1 M DT (T-87600, SRT, “Ovarian Follicle”)
3 > HAS CONCEPT MOD CODE EV (G-C171, SRT, “Laterality”) 1 M $Laterality
4 > CONTAINS NUM $Number 1 U
5 > CONTAINS INCLUDE DTID (5014) Follicle Measurement Group 1-n U

TID 5014 Follicle Measurement Group

This template contains metrics for one ovarian follicle.

TID 5014FOLLICLE MEASUREMENT GROUPType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER EV (125007, DCM, “Measurement Group”) 1 M
2 > HAS OBS CONTEXT TEXT EV (125010, DCM, “Identifier”) 1 U Unique among all groups of same laterality
3 > CONTAINS INCLUDE DTID (300) Measurement 1 U $Measurement = EV (G-D705, SRT, “Volume”)
4 > CONTAINS INCLUDE DTID (300) Measurement 1-n U $Measurement = EV (11793-7, LN, “Follicle Diameter”) $Derivation = DCID (3627) Measurement Type

TID 5015 Pelvis and Uterus Section

This template contains general measurements in the pelvis and uterus.

TID 5015PELVIS AND UTERUS SECTIONType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DT (125011, DCM, “Pelvis and Uterus”) 1 M
2 > CONTAINS INCLUDE DTID (5016) LWH Volume Group 1 U $GroupName = EV (T-83000, SRT, ”Uterus”) $Width = EV (11865-3,LN,” Uterus Width”) $Length = EV (11842-2, LN,” Uterus Length”) $Height = EV (11859-6, LN,” Uterus Height”) $Volume = EV (33192-6, LN, ”Uterus Volume”)
3 > CONTAINS INCLUDE DTID (300) Measurement 1-n U $Measurement = DCID (12011) Ultrasound Pelvis and Uterus $Derivation = DCID (3627) Measurement Type

TID 5016 LWH Volume Group

This template is a container for a group of measurements that assess the size of an anatomical structure using a volume derived from perpendicular diameters.

TID 5016 Parameters

Parameter Name Parameter Usage
$GroupName The name of the volume group
$Volume Concept name of volume measurement
$Length Concept name of length measurement
$Width Concept name of width measurement
$Height Concept name of height measurement

TID 5016LWH VOLUME GROUPType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER $GroupName 1 M
2 > CONTAINS INCLUDE DTID (300) Measurement 1 MC At least one of row 2,3,4,5 shall be present $Measurement = $Volume
3 > CONTAINS INCLUDE DTID (300) Measurement 1-n MC At least one of row 2,3,4,5 shall be present $Measurement = $Length $Derivation = DCID (3627) Measurement Type
4 > CONTAINS INCLUDE DTID (300) Measurement 1-n MC At least one of row 2,3,4,5 shall be present $Measurement = $Width $Derivation = DCID (3627) Measurement Type
5 > CONTAINS INCLUDE DTID (300) Measurement 1-n MC At least one of row 2,3,4,5 shall be present $Measurement = $Height $Derivation = DCID (3627) Measurement Type

TID 5025 OB-GYN Fetal Vascular Ultrasound Measurement Group

This template is an anatomy specific container of OB-GYN fetal vascular measurements.

Parameter Name Parameter Usage
$AnatomyGroup The concept name of the vascular anatomy

TID 5025 OB-GYN FETAL VASCULAR ULTRASOUND MEASUREMENT GROUPType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER $AnatomyGroup 1 M
2 > HAS OBS CONTEXT INCLUDE DTID (1008) Subject Context, Fetus 1 MC IF this template is invoked more than once to describe more than one fetus
3 > HAS CONCEPT MOD CODE EV (G-C171, SRT “Laterality”) 1 MC IFF anatomy has laterality DCID (244) Laterality
4 > CONTAINS INCLUDE DTID (300) Measurement 1-n M $MeasType = DCID (12119) Vascular Ultrasound Property $Derivation = DCID (3627) Measurement Type

Content Item Descriptions

Anatomy Group Specifies the anatomical context of the observations in the group.

TID 5026 OB-GYN Pelvic Vascular Ultrasound Measurement Group

This template is an anatomy specific container of OB-GYN pelvic vascular measurements.

Parameter Name Parameter Usage
$AnatomyGroup The concept name of the vascular anatomy

TID 5026 OB-GYN PELVIC VASCULAR ULTRASOUND MEASUREMENT GROUPType: Extensible Order: Significant

NL Rel with Parent VT Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER $AnatomyGroup 1 M
2 > HAS CONCEPT MOD CODE EV (G-C171, SRT, “Laterality”) 1 MC IFF anatomy has laterality DCID (244) Laterality
3 > HAS CONCEPT MOD TEXT (112050, DCM, “Anatomic Identifier”) 1 U
4 > CONTAINS INCLUDE DTID (300) Measurement 1-n M $MeasType = DCID (12119) Vascular Ultrasound Property $Derivation = DCID (3627) Measurement Type
5 >> HAS CONCEPT MOD CODE EV (125105, DCM, “Measurement Orientation”) 1 U DCID (12118) Measurement Orientation
6 >> HAS CONCEPT MOD NUM EV (125106, DCM, “Doppler Angle”) 1 U UNIT = EV (deg, UCUM , ”degrees”)
7 >> HAS CONCEPT MOD NUM EV (125107, DCM, “Sample Volume Depth”) 1 U UNIT = EV (cm, UCUM , ”cm”)

Content Item Descriptions

Row 1 Specifies the anatomical context of the observations in the group.
Row 3 Differentiates between multiple structures such as the two umbilical arteries.