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