PROCEDURE LOG IOD TEMPLATES

TID 3001 Procedure Log

The Procedure Log template is intended for the representation of reports or logs of time-stamped events occurring during an image-guided interventional or other procedure.

This Template does not require a particular ordering of the subsidiary Content Items.

Notes: 1. The Procedure Log IOD (PS3.3) requires ordering by Observation DateTime; thus log entries of different types (i.e., specified by different Rows in the Template) may appear in any order.2. While this Template is extensible, the Procedure Log IOD forbids Container Content Items subsidiary to the top level Container.

TID 3001 Procedure Log Type: Extensible Order: Non-Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CONTAINER DCID (3400) Procedure Log Titles 1 M
2 > INCLUDE DTID (1002) Observer Context 1-n M
3 > INCLUDE DTID (3601) Procedure Context 1 M
4 > HAS ACQ CONTEXT TEXT EV (121121, DCM, "Room identification") 1 U
5 > HAS ACQ CONTEXT TEXT EV (121122, DCM, "Equipment identification") 1-n U
6 > CONTAINS TEXT DCID (3401) Types of Log Notes 1-n U
7 >> INCLUDE DTID (3010) Log Entry Qualifiers 1 U
8 > CONTAINS CODE EV (121123, DCM, “Patient Status or Event”) 1-n U DCID (3402) Patient Status and Events
9 >> INCLUDE DTID (3010) Log Entry Qualifiers 1 U
10 > CONTAINS PNAME DCID (3404) Staff Actions 1-n U
11 >> INCLUDE DTID (3010) Log Entry Qualifiers 1 U
12 > CONTAINS TEXT DCID (3427) Equipment Events 1-n U Equipment identifier
13 >> INCLUDE DTID (3010) Log Entry Qualifiers 1 U
14 > CONTAINS INCLUDE DTID (3100) Procedure Action 1-n U
15 > CONTAINS INCLUDE DTID (3101) Image Acquisition 1-n U
16 > CONTAINS INCLUDE DTID (3102) Waveform Acquisition 1-n U
17 > CONTAINS INCLUDE DTID (3103) Referenced Object 1-n U
18 > CONTAINS INCLUDE DTID (3104) Consumables 1-n U
19 > CONTAINS INCLUDE DTID (3105) Lesion Identification and Properties 1-n U
20 > CONTAINS INCLUDE DTID (3106) Drugs/Contrast Administered 1-n U
21 > CONTAINS INCLUDE DTID (3107) Device Used 1-n U
22 > CONTAINS INCLUDE DTID (3108) Intervention 1-n U
23 > CONTAINS CODE EV (DD-60002, SRT, “Complication of Procedure”) 1-n U DCID (3413) Adverse Outcomes
24 >> INCLUDE DTID (3010) Log Entry Qualifiers 1 U
25 > CONTAINS INCLUDE DTID (3109) Measurements 1-n U
26 > CONTAINS INCLUDE DTID (3110) Impressions or Findings 1-n U
27 > CONTAINS INCLUDE DTID (3111) Percutaneous Entry 1-n U
28 > CONTAINS INCLUDE DTID (3112) Specimen Obtained 1-n U
29 > CONTAINS INCLUDE DTID (3113) Patient Support 1-n U
30 > CONTAINS INCLUDE DTID (3114) Patient assessment 1-n U
31 > CONTAINS INCLUDE DTID (3115) ECG ST assessment 1-n U

Content Item Descriptions

Row 2 includes TID 1002 Observer Context. TID 1002 shall be used to record the identity of the person responsible for recording the log, as well as all other participants in the procedure, even though these personnel may not technically be "observers" of the Procedure Log. As participants in the procedure, they are potential sources for events and observations recorded in the Log. TID 1002 allows the specification of the person’s role in the organization (e.g., physician, nurse), as well as the role in the procedure (e.g., circulating, performing, etc.).

Row 5 shall be used to record the identity of the major equipment used in the procedure.

Row 6 may be used to record any event not covered by a specific log entry template.

TID 3010 Log Entry Qualifiers

The Log Entry Qualifiers Template provides a common means for adding additional description to a procedure log content item. It allows identification of a source for the procedure log entry (other than the recording observer for the log as a whole), a free text comment, a link to a particular Procedure Action item, a link to a particular lesion, or the date/time of recording (if different than the time of the event occurrence recorded in the Observation DateTime of the parent content item).

TID 3010Log Entry QualifiersType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 INCLUDE DTID (1000) Quotation 1 U
2 HAS PROPERTIES TEXT EV (121106, DCM, “Comment”) 1 U
3 HAS OBS CONTEXT TEXT EV (121124, DCM, "Procedure Action ID") 1-n U
4 HAS OBS CONTEXT TEXT EV (121151, DCM, "Lesion Identifier") 1-n U Up to 3 numeric characters
5 HAS OBS CONTEXT DATETIME EV (121125, DCM, "DateTime of Recording of Log Entry") 1 U
6 INFERRED FROM IMAGE 1-n U
7 INFERRED FROM WAVEFORM 1-n U
8 INFERRED FROM COMPOSITE 1-n U
9 HAS OBS CONTEXT CODE EV (121135, DCM, ”Observation DateTime Qualifier”) 1 U DCID (3430) DateTime Qualifiers

Content Item Descriptions

Row 3 Procedure Action ID allows linking recorded events to a particular action, step, or phase of a procedure. See description for TID 3100 Procedure Action.

Row 4 Lesion Identifier is specified as a numeric text string, and allows linking recorded events to the diagnosis or therapy of particular lesion. See description for TID 3105 Lesion Identifier.

TID 3100 Procedure Action

The Procedure Action Template is intended for the recording of the beginning or end of procedure steps or action items in a procedure. The level of granularity of the recorded events is not specified, and may vary between institutions, or even be at multiple levels within a single procedure log. There is no requirement for the real-world procedure step or action item recorded with this template to end before another one begins; there may be overlapping or simultaneous procedure steps or action items.

This log entry template may be used to record the start or stop of timers.

Other recorded events in the procedure may be linked to a particular step or action item by Procedure Action ID (see TID 3010 Log Entry Qualifiers).

TID 3100Procedure ActionType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE DCID (3421) Procedure Action 1 M BCID (3405) Procedure Action Values
2 > HAS PROPERTIES TEXT EV (121124, DCM, "Procedure Action ID") 1 M
3 > HAS PROPERTIES PNAME BCID (7453) Performing Roles 1-n U
4 > HAS PROPERTIES NUM EV (121128, DCM, "Procedure Action Duration") 1 U
5 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
6 > HAS PROPERTIES UIDREF EV (121126, DCM, "Performed Procedure Step SOP Instance UID") 1 MC IFF DICOM Modality or General Purpose Performed Procedure Step SOP Class is used to provide status of the Procedure Step
7 > HAS PROPERTIES UIDREF EV (121127, DCM, "Performed Procedure Step SOP Class UID") 1 MC IFF DICOM Modality or General Purpose Performed Procedure Step SOP Class is used to provide status of the Procedure Step

Content Item Descriptions

Row 2 - The value of the Procedure Action ID shall be uniquely associated with the step or action within the context of the Study, and may be used to associate various Procedure Log entries with the step or action.

Row 3 may be used to record the identity of staff roles for the purpose of this Procedure Action, which may differ from their roles in the procedure as a whole.

TID 3101 Image Acquisition

The Image Acquisition Template allows recording of the essential parameters of a digital image acquired during the procedure.

TID 3101 Image Acquisition Type: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 IMAGE EV (121138, DCM, “Image Acquired”) 1 M
2 > HAS ACQ CONTEXT UIDREF EV (112002, DCM, "Series Instance UID") 1 M
3 > HAS ACQ CONTEXT CODE EV (121139, DCM, “Modality”) 1 M DCID (29) Acquisition Modality Derived from referenced image SOP Instance attribute (0008,0060)
4 > HAS PROPERTIES NUM EV (121140, DCM, “Number of Frames”) 1 U
5 > HAS PROPERTIES TEXT EV (121141, DCM, “Image Type”) 1 U From referenced image SOP Instance attribute (0008,0008)
6 > HAS ACQ CONTEXT NUM EV (112011, DCM, “Positioner Primary Angle”) 1 U UNITS = EV (deg, UCUM, “º”)
7 > HAS ACQ CONTEXT NUM EV ( 112012, DCM, “Positioner Secondary Angle”) 1 U UNITS = EV (deg, UCUM, “º”)
8 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3102 Waveform Acquisition

The Waveform Acquisition Template allows recording of the essential parameters of a digital waveform acquired during the procedure.

TID 3102Waveform AcquisitionType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 WAVEFORM EV (121143, DCM, “Waveform Acquired”) 1 M
2 > HAS ACQ CONTEXT CODE EV (121139, DCM, “Modality”) 1 M DCID (29) Acquisition Modality Derived from referenced waveform SOP Instance attribute (0008,0060)
3 > HAS ACQ CONTEXT NUM EV (121142, DCM, “Acquisition Duration”) 1 U
4 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3103 Referenced Object

The Referenced Object Template allows reference to measurement or report objects, such as prior medical reports, laboratory results, hemodynamic measurement reports, or quantitative analysis reports.

TID 3103Referenced ObjectType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 COMPOSITE BCID (3407) Purpose of Reference to Object 1 M
2 > HAS PROPERTIES CODE EV (121144, DCM, “Document Title") 1 MC IFF Row 1 references an SR object Root node concept of referenced SR object
3 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3104 Consumables

The Consumables Template allows recording of devices (e.g., catheters or stents), drugs, or contrast agents accessed in a procedure. This content item is directed towards inventory control and billing. The actual clinical use of the particular consumable is recorded using TID 3106 Drugs/Contrast Administered or TID 3107 Device Used.

This template allows recording both consumable retrieval from, and return to, inventory or stock, and disposal of used material. The quantity involved in each recorded transaction may be specified.

TID 3104ConsumablesType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE DCID (3408) Actions with Consumables 1 M Vendor or local bar coded values
2 > HAS PROPERTIES TEXT DCID (3426) Consumables Parameters 1-n U
3 > HAS PROPERTIES NUM EV (121146, DCM, "Quantity of Material") 1 U
4 > HAS PROPERTIES CODE EV (121147, DCM, "Billing Code") 1 U local billing codes
5 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3105 Lesion Identification and Properties

The Lesion Identification and Properties Template allows recording the identification of each lesion addressed in a procedure. The lesion identifier may be used to relate diagnostic or therapeutic actions with their target lesion (see Row 4 in TID 3010 Log Entry Qualifiers). This content item may include the initial visually estimated measurements of stenosis or TIMI flow; measured values from a quantitative measurement report may be referenced indirectly (through TID 3103 Referenced Object), or by quotation (TID 3109 Measurements template). Subsequent (e.g., post-intervention) stenosis measurements may be encoded using TID 3109 Measurements, with the Lesion Identifier conveyed through its subsidiary TID 3010 Log Entry Qualifiers template.

TID 3105Lesion Identification and PropertiesType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 TEXT EV (121151, DCM, “Lesion Identifier") 1 M Up to 3 numeric characters
2 > HAS PROPERTIES CODE EV (G-C0E3, SRT, “Finding Site”) 1 M DCID (3604) Arterial lesion locations
3 >> HAS CONCEPT MOD CODE EV (G-A1F8, SRT, “Topographical modifier") 1 U DCID (3019) Cardio-vascular Anatomic Location Modifiers
4 > HAS PROPERTIES CODE EV (121153, DCM, “Lesion Risk") 1 U DCID (3418) Lesion Risk
5 > HAS PROPERTIES NUM (R-101BB, SRT, “Lumen Diameter Stenosis”) 1 U UNITS = EV (%, UCUM, "%")
6 >> HAS CONCEPT MOD CODE EV (G-72BB, SRT, “Catheterization Procedure Phase”) 1 M EV (G-7293, SRT, “Baseline Phase”)
7 >> HAS CONCEPT MOD CODE EV (121401, DCM, “Derivation”) 1 U DCID (3745) Calculation Method
8 > HAS PROPERTIES CODE EV (122109, DCM, "Baseline TIMI Flow") 1 UC IFF Row 2 specifies a coronary artery DCID (3713) TIMI Flow Characteristics
9 > HAS PROPERTIES CODE EV (122131, DCM, "Degree of Thrombus") 1 U DCID (3714) Thrombus
10 > HAS PROPERTIES CODE EV (F-01740, SRT, “Lesion Margin Characteristics”) 1 U DCID (3715) Lesion Margin
11 > HAS PROPERTIES CODE EV (122134, DCM, "Vessel Morphology") 1-n U DCID (3712) Vessel Descriptors
12 > HAS PROPERTIES CODE EV (122132, DCM, "Severity of Calcification") 1 U DCID (3716) Severity
13 > HAS PROPERTIES IMAGE DT (121080, DCM, "Best illustration of finding" 1 U
14 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

Content Item Descriptions

Row 1 Lesion Identifier is specified as a numeric text string in order to facilitate transcoding to DICOM Attribute (0018,3105) Lesion Number and to formats for outcomes registries, such as the ACC National Cardiovascular Data Registry™.

TID 3106 Drugs/Contrast Administered

The Drugs/Contrast Administered Template allows the recording of the start or end of that type of event, together with its parameters. If start and end are represented by a single log entry (e.g., for an injection), the concept name “Drug/contrast administered” shall be used.

TID 3106 Drugs/Contrast Administered Type: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE DCID (3409) Administration of Drugs/Contrast 1 M BCID (10) Interventional Drug, or BCID (12) Radiographic Contrast Agent
2 > HAS PROPERTIES TEXT EV (121145, DCM, "Description of Material") 1 U
3 > HAS PROPERTIES CODE EV (G-C340, SRT, "Route of administration") 1 U BCID (11) Route of Administration
4 > HAS PROPERTIES NUM DCID (3410) Numeric Parameters of Drugs/Contrast 1-n U
5 > HAS PROPERTIES PNAME EV (121152, DCM, “Person administering drug/contrast”) 1 U
6 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3107 Device Used

The Device Used Template allows recording of the use of interventional diagnostic and therapeutic devices.

The identification of one device used to deploy another device (e.g., a balloon catheter to deploy a stent) may be described with two entries, with one identified as a deployment device in the Concept Modifier of Row 6 of this template, and linked by the same Procedure Action ID in the Log Entry Qualifiers of the included TID 3010.

TID 3107Device UsedType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE DCID (3422) Device Use Actions 1 M BCID (3429) Catheterization Devices
2 > HAS PROPERTIES CODE EV (121150, DCM, "Device Code") 1-n U Vendor or local bar coded values
3 > HAS PROPERTIES TEXT EV (121145, DCM, "Description of Material") 1 U
4 > HAS PROPERTIES NUM DCID (3423) Numeric Device Characteristics 1-n U
5 > HAS PROPERTIES CODE EV (G-C0E9, SRT, “Procedure site”) 1 U BCID (3630) Cardiovascular Anatomic Locations
6 > HAS CONCEPT MOD CODE EV (G-C0E8, SRT, “Has Intent") 1 U DT (121155, DCM, “Deployment")
7 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3108 Intervention

The Intervention Template allows recording of interventions, including atherectomy, angioplasty, stent placement, brachytherapy, etc. The record may include reference to an image that documents the intervention.

TID 3108 Intervention Type: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (122090, DCM, "Intervention Action") 1 M DCID (3412) Intervention Actions and Status
2 > HAS PROPERTIES CODE EV (G-C0E9, SRT, “Procedure site”) 1 M DCID (3604) Arterial Lesion Locations
3 >> HAS CONCEPT MOD CODE EV (G-A1F8, SRT, “Topographical modifier") 1 U DCID (3019) Cardio-vascular Anatomic Location Modifiers
4 > HAS PROPERTIES TEXT EV (121154, DCM, "Intervention attempt identifier") 1 M Up to 3 numeric characters
5 > HAS PROPERTIES CODE EV (G-C50A, SRT, "Uses Equipment") 1-n U BCID (3411) Intracoronary Devices
6 >> HAS CONCEPT MOD CODE EV (122111, DCM, "Primary Intervention Device") 1 MC IF Device is Primary for this Lesion DCID (230) Yes-No
7 > HAS PROPERTIES NUM DCID (3425) Intervention Parameters 1-n U
8 > HAS PROPERTIES IMAGE BCID (7003) Diagnostic Imaging Report Purposes of Reference 1 U
9 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

Content Item Descriptions

Row 4 Intervention attempt Identifier is specified as a numeric text string, and shall be treated as the ordinal of the recorded attempted intervention within this procedure (i.e., “1” for the first attempted intervention, “2” for the second, etc.).

TID 3109 Measurements

The Measurements Template allows recording of significant measurements, such as vital signs, laboratory results, hemodynamic measurements, or quantitative analysis measurements. These measurements are often quoted from another source, which would be documented in the included TID 3010 Log Entry Qualifiers.

TID 3109MeasurementsType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 NUM No BCID 1 U
2 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
3 > HAS PROPERTIES INCLUDE DTID (310) Measurement Properties 1 U
4 CODE No BCID 1 U
5 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3110 Impressions or Findings

The Impressions or Findings Template allows the recording of unconfirmed (provisional) impressions or findings noted during the procedure. It is not intended to convey the Cath Lab Clinical Report (the formal report from the performing physician), although it may be used (like any Procedure Log entry) for the subsequent construction of the Cath Lab Clinical Report.

A finding that is supported by a specific image frame may reference that image in the INFERRED FROM / IMAGE row of the included TID 3010 Log Entry Qualifiers template.

TID 3110 Impressions or FindingsType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (121071, DCM, "Finding") 1 U BCID (3728) Cath Findings
2 > HAS PROPERTIES CODE EV (G-C197, SRT, "Severity") 1 U DCID (3716) Severity
3 > HAS PROPERTIES CODE EV (G-C0E3, SRT, “Finding Site”) 1 U
4 >> HAS CONCEPT MOD CODE EV (G-A1F8, SRT, “Topographical modifier") 1 U DCID (3019) Cardio-vascular Anatomic Location Modifiers
5 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
6 TEXT BCID (3419) Findings Titles 1 U
7 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

Content Item Descriptions

Row 3 Finding Site has no Baseline Context ID specified. Typically terms would be drawn from coronary segments, other arterial segments, myocardial segments, etc.

TID 3111 Percutaneous Entry

The Percutaneous Entry Template allows recording of the opening or closing of invasive access ports.

TID 3111Percutaneous EntryType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (121156, DCM, “Percutaneous Entry Action”) 1 M DCID (3403) Percutaneous Entry
2 > HAS CONCEPT MOD CODE EV (G-C171, SRT, “Laterality") 1 U DCID (244) Laterality
3 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3112 Specimen Obtained

The Specimen Obtained Template allows recording of obtaining a specimen, and the identifiers for that specimen. This is particularly designed for blood samples that will be analyzed for blood oxygen-related measurements. The analysis of the sample may be recorded in one or more log entries using TID 3109 Measurements Template, or in a separate Structured Report SOP Instance referenced by a log entry using TID 3103 Referenced Object Template.

TID 3112Specimen ObtainedType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (121123, DCM, “Patient Status or Event”) 1 M DCID (3515) Specimen Collection
2 > HAS ACQ CONTEXT CODE EV (R-00254, SRT, "Specimen Type”) 1 UC IFF specimen is blood sample DCID (3520) Blood Source Type
3 > HAS ACQ CONTEXT CODE EV (G-C0E9, SRT, “Procedure site”) 1 U BCID (3630) Cardiovascular Anatomic locations
4 > HAS PROPERTIES INCLUDE DTID (1009) Subject Context, Specimen 1 U

TID 3113 Patient Support

The Patient Support Template allows recording of the use of various support technologies, including oxygen, ventilation, pacing, etc.

TID 3113 Patient Support Type: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE DCID (3530) Oxygen Administration Actions 1 U DCID (3531) Oxygen Administration
2 > HAS PROPERTIES NUM EV (121160, DCM, “Oxygen Administration Rate") 1 MC IFF Row 1 Concept is (121161, DCM, "Begin Oxygen Administration") Units = DT (l/min, UCUM, "l/min")
3 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
4 CODE DCID (3550) Circulatory Support Actions 1 U DCID (3553) Circulatory Support
5 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
6 CODE DCID (3551) Ventilation Actions 1 U DCID (3554) Ventilation
7 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U
8 CODE DCID (3552) Pacing Actions 1 U DCID (3555) Pacing
9 > INCLUDE DTID (3010) Log Entry Qualifiers 1 U

TID 3114 Patient Assessment

The Patient Assessment Template allows recording of the assessment of the patient’s cardiovascular, neurological, and/or respiratory condition. A particular use of this template is for “vital signs”, which are a specific subset of mandatory patient assessment measurements.

TID 3114 Patient Assessment Type: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (121123, DCM, “Patient Status or Event”) 1 M DT (121165, DCM, “Patient Assessment Performed”) or DT (PA-00500, SRT, “Observation of Vital Signs”)
2 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (F-008EC, SRT, "Systolic blood pressure") $Units = DCID (3500) $Method = BCID (3560) Blood Pressure Methods
3 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (F-008ED, SRT, "Diastolic blood pressure") $Units = DCID (3500)
4 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (8867-4, LN, "Heart rate") $Units = EV ("{H.B.}/min", UCUM, "BPM")
5 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (8310-5, LN, "Body temperature") $Units = EV (Cel, UCUM, “°C”)
6 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = DCID (3526) Blood gas saturation $Units = EV (%, UCUM, "%")
7 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (F-043E7, SRT, "Respiration rate") $Units = EV (/min, UCUM, "breaths/min")
8 > HAS PROPERTIES INCLUDE TID (300) Measurement 1-n MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (122195, DCM, "Pulse Strength") $Method = BCID (3442) Peripheral Pulse Methods $TargetSite = BCID (3440) Peripheral Pulse Locations $Units = DT ("{0:4}", UCUM, "range 0:4")
9 > HAS PROPERTIES INCLUDE TID (300) Measurement 1 MC IF Row 1 value = (PA-00500, SRT, “Observation of Vital Signs”) $Measurement = EV (F-009EA, SRT, “Pain Score”) $Units = DT ("{1:10}", UCUM, "range 1:10")
10 > HAS PROPERTIES CODE DT (8884-9, LN, "Cardiac Rhythm") 1 U BCID (3415) Cardiac Rhythms
11 > HAS PROPERTIES CODE DT (9304-7, LN, "Respiration Rhythm") 1 U BCID (3416) Respiration Rhythms
12 > HAS PROPERTIES CODE DT ( F-043E6, SRT, “Respiration Assessment”) 1 U BCID (3448) Airway Assessment
13 > HAS PROPERTIES CODE DT (F-046D8, SRT, “Skin condition") 1-n U BCID (3446) Skin Condition
14 > HAS PROPERTIES CODE DT (F-04317, “Patient mental state assessment”) 1 U No BCID
15 > HAS PROPERTIES TEXT BCID (3441) Patient Assessments 1-n U

Content Item Descriptions

Row 8 Pulse Strength allows the assessment of the patient’s pulse at multiple locations using the Topographical concept modifier. It may also be used for a single pulse strength measurement from an unspecified location, as is typical of vital signs assessments.

Row 16 allows free text description of patient assessments that are not expressible by coded entries of Rows 10 to 14.

TID 3115 ECG ST Assessment

The ECG ST Assessment Template allows recording of the assessment of changes in the patient ECG relative to baseline.

TID 3115ECG ST AssessmentType: Extensible Order: Significant

NL Relation with Parent Value Type Concept Name VM Req Type Condition Value Set Constraint
1 CODE EV (121123, DCM, “Patient Status or Event”) 1 M DT (R-41D8B, SRT, “ECG Analysis”)
2 > HAS PROPERTIES NUM DT (122099, DCM, “ST change from baseline”) 1-n M Units = EV(uV, UCUM, “uV”)
3 >> HAS CONCEPT MOD CODE DT (122148, DCM, "Lead ID") 1 M BCID (3001) ECG Leads