Annex I Ultrasound Templates (Informative)

I.1 SR Content Tree Structure

The templates for ultrasound reports are defined in PS 3.16, Annex A, DCMR Templates. The following figure is an outline of the common elements of ultrasound structured reports.

Figure I.1-1 Top Level Structure of Content Tree

The Patient Characteristics Section is for medical data of immediate relevance to administering the procedure and interpreting the results. This information may originate outside the procedure.

The Procedure Summary Section contains exam observations of immediate or primary significance. This is key information a physician typically expects to see first in the report.

Measurements typically reside in a measurement group container within a Section. Measurement groups share context such as anatomical location, protocol or type of analysis. The grouping may be specific to a product implementation or even to a user configuration. OB-GYN measurement groups have related measurements, averages and other derived results.

If present, the Image Library contains a list of images from which observations were derived. These are referenced from the observations with by-reference relationships.

I.2 Procedure Summary

The Procedure Summary Section contains the observations of most immediate interest. Observations in the procedure summary may have by-reference relationships to other content items.

I.3 Multiple Fetuses

Where multiple fetuses exist, the observations specific to each fetus must reside under separate section headings. The section heading must specify the fetus observation context and designate so using Subject ID (121030,DCM, “Subject ID”) and/or numerical designation (121037,DCM, “Fetus Number”) as shown below. See TID 1008 Subject Context, Fetus.

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Figure I.3-1 Multiple Fetuses

I.4 Explicitly Specifying Calculation Dependencies

Reports may specify dependencies of a calculation on its dependent observations using by-reference relationships. This relationship must be present for the report reader to know the inputs of the derived value.

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Figure I.4-1 Explicit Dependencies

I.5 Linking Measurements to Images, Coordinates

Optionally, the relationship of an observation to its image and image coordinates can be encoded with by-reference content items as the following figure shows. For conciseness, the by-reference relationship points to the content item in the Image Library, rather than directly to the image.

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Figure I.5-1 Relationships to Images and Coordinates

R-INFERRED FROM relationships to IMAGE content items specify that the image supports the observation. A purpose of reference in an SCOORD content item may specify an analytic operation (performed on that image) that supports or produces the observation.

I.6 OB Patterns

A common OB-GYN pattern is that of several instances of one measurement type (e.g. BPD), the calculated average of those values, and derived values such as a gestational age calculated according to an equation or table. The measurements and calcuations are all siblings in the measurement group. A child content item specifies the equation or table used to calculate the gestational age. All measurement types must relate to the same biometric type. For example, it is not allowed to mix a BPD and a Nuchal Fold Thickness measurement in the same biometry group.

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Figure I.6-1 OB Numeric Biometry Measurement group Example

The example above is a gestational age calculated from the measured value. The relationship is to an equation or table. The inferred from relationship identifies equation or table in the Concept Name. Codes from Context Group CID 12013 Gestational Age Equations and Tables identify the specific equation or table.

Another use case is the calculation of a growth parameter’s relationship to that of a referenced distribution and a known or assumed gestational age. Context Group CID 12015 Fetal Growth Equations and Tables identify the growth table. The figure below shows the assignment of a percentile for the measured BPD, against the growth of a referenced population. The dependency relationship to the gestational age is a by-reference relationship to the established gestational age. Though the percentile rank is derived from the BPD measurement, a by-reference relationship is not essential if one BPD has a concept modifier indicating that it is the mean or has selection status (see TID 300). A variation of this pattern is the use of Z-score instead of percentile rank. Not shown is the expression of the normal distribution mean, standard deviation, or confidence limits.

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Figure I.6-2 Percentile Rank or Z-score Example

Estimated fetal weight (EFW) is a fetus summary item as shown below. It is calculated from one or more growth parameters (the inferred from relationships are not shown). The Equation or Table Template TID 315 allows specifying how the value was derived. Terms from Context Group CID 12014 specify the table or equation that yields the EFW from growth parameters.

“EFW percentile rank” is another summary term. By definition, this term depends upon the EFW and the population distribution of the ranking. A Reference Authority content item identifies the distribution. Context Group CID12016 is list of established reference authorities.

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Figure I.6-3 Estimated Fetal Weight

I.7 Selected Value

When multiple observations of the same type exist, one of these may be the selected value. Typically, this value is the average of the others, or it may be the last entered, or user chosen. The Measurement Properties Template TID 310 provides a content item with concept name of (121404, DCM, “Selection Status”) and a value set specfied by DCID 224 Selection Method.

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Figure I.7-1 Selected Value Example

There are multiple ways that a measurement may originate. The measurement value may result as an output of an image interactive, system tool. Alternatively, the user may directly enter the value, or the system may create a value automatically as the mean of multiple measurement instances. The Measurement Template TID 300 provides that a concept modifier of the numeric content item specify the derivation of the measurement. The concept name of the modifier is (121401, DCM, “Derivation”). CID 3627 Measurement Type provides concepts of appropriate measurement modifiers. The figure below illustrates such a case.

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Figure I.7-2 Selected Value with Mean Example

I.8 OB-GYN Examples

The following are simple, non-comprehensive illustrations of report sections.

Example 1: OB-GYN Root with Observation Context

The following example shows the highest level of content items for a second or third trimester OB exam. Subsequent examples show details of section content,

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.1 Language of Content Item and Descendants English 1204
1.2 Subject Name Jane Doe 1007
1.3 Subject ID 123-45-6789 1007
1.4 Procedure Study Instance UID 1.2.842.111724.7678.32.34 1005
1.5 Procedure Study Component UID 1.2.842.111724.7678.55.34 1005
1.6 Procedure Accession Number 20011007-21 1005
1.7 Image Library 5000
1.7.1 IMAGE 1 5000
1.7.2 IMAGE 2 5000
1.7.n IMAGE N 5000
1.8 Patient Characteristics 5001
1.8.n 5001
1.9 Summary 5002
1.9.n 5002
1.10 Fetal Biometry Ratios 5004
1.10.n 5004
1.11 Long Bones 5006
1.11.n 5006
1.12 Fetal Cranium 5007
1.12.n 5007
1.13 Biophysical Profile 5009
1.13.n 5009
1.14 Amniotic Sac 5010
1.14.n 5010

The following example shows the highest level of content items for a GYN exam. Subsequent examples show details of section content.

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.1 Subject Name Jane Doe 1007
1.2 Subject ID 123-45-6789 1007
1.3 Image Library 5000
1.3.1 IMAGE 1 5000
1.3.2 IMAGE 2 5000
1.3.n IMAGE N 5000
1.4 Patient Characteristics 5001
1.4.n 5001
1.5 Findings 5012
1.5.1 Findings Site Ovary 5012
1.5.n 5012
1.6 Findings 5013
1.6.1 Findings Site Ovarian Follicle 5013
1.6.2 Laterality Left 5013
1.6.n 5013
1.7 Findings 5013
1.7.1 Findings Site Ovarian Follicle 5013
1.7.2 Laterality Right 5013
1.7.n 5013
1.8 Pelvis and Uterus 5015
1.8.n 5015

Example 2: OB-GYN Patient Characteristics and Procedure Summary

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
…. 5000
1.8 Patient Characteristics 5001
1.8.1 Gravida 5 5001
1.8.2 Para 3 5001
1.8.3 Aborta 2 5001
1.8.4 Ectopic Pregnancies 1 5001
1.9 Summary 5002
1.9.1 LMP 20010101 5002
1.9.2 EDD 20010914 5002
1.9.3 EDD from LMP 20010914 5002
1.9.4 EDD from average ultrasound age 20010907 5002
1.9.5 Gestational age by ovulation date 185 d 5002
1.9.6 Fetus Summary 5003
1.9.6.1 EFW 2222 g 300
1.9.6.1.1 +/-, range of measurement uncertainty 200 g 310
1.9.6.1.2 Equation EFW by AC, BPD, Hadlock 1984 315
1.9.6.2 Comment Enlarged cisterna magna 5003
1.9.6.3 Comment Choroid plexus cyst 5003

Example 3: OB-GYN Multiple Fetus

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.5 Summary 5002
1.5.1 EDD from LMP 20020325 5002
1.5.2 Fetus Summary 5003
1.5.2.1 Fetus ID A 1008
1.5.2.2 EFW 1.6 Kg 300
1.5.2.2.1 Equation EFW by AC, BPD, Hadlock 1984 315
1.5.2.2.2 +/-, range of measurement uncertainty 160g 310
1.5.2.3 Fetal Heart Rate 120 {H.B.}/min 300
1.5.3 Fetus Summary 5003
1.5.3.1 Fetus ID B 1008
1.5.3.2 Comment Choroid plexus cyst 5003
1.5.3.3 EFW 1.4 kg 300
1.5.3.3.1 Equation EFW by AC, BPD, Hadlock 1984 315
1.5.3.3.2 +/-, range of measurement uncertainty 140 g 310
1.5.3.4 Fetal Heart Rate 135 {H.B.}/min 300
1.6 Biophysical Profile 5009
1.6.1 Fetus ID A 1008
1.6.n
1.7 Biophysical Profile 5009
1.7.1 Fetus ID B 1008
1.7.n

Example 4: Biophysical Profile

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.9 Biophysical Profile 5009
1.9.1 Gross Body Movement 2 {0:2} 5009
1.9.2 Fetal Breathing 2 {0:2} 5009
1.9.3 Fetal Tone 2 {0:2} 5009
1.9.4 Fetal Heart Reactivity 2 {0:2} 5009
1.9.5 Amniotic Fluid Volume 2 {0:2} 5009
1.9.6 Biophysical Profile Sum Score 10 {0:10} 5009

Example 5: Biometry Ratios

Optionally, but not shown, the ratios may have by-reference, inferred-from relationships to the content items holding the numerator and denominator values.

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.9 Fetal Biometry Ratios 5004
1.9.1 HC/AC 77% 5004
1.9.2 FL/AC 22 % 5004
1.9.2.1 Normal Range Lower Limit 20 % 312
1.9.2.2 Normal Range Upper Limit 24 % 312
1.9.2.3 Normal Range Authority Hadlock, AJR 1983 312
1.9.3 FL/BPD 79 % 5004
1.9.3.1 Normal Range Lower Limit 71 % 312
1.9.3.2 Normal Range Upper Limit 81 % 312
1.9.3.3 Normal Range Authority Hohler, Am J of Ob and Gyn 1981 312
1.9.4 Cephalic Index 82 % 5004
1.9.4.1 Normal Range Lower Limit 70 % 312
1.9.4.2 Normal Range Upper Limit 86 % 312
1.9.4.3 Normal Range Authority Hadlock, AJR 1981 312

Example 6: Biometry

This example shows measurements and estimated gestational age.

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.8 Fetal Biometry 5005
1.8.1 Biometry Group 5008
1.8.1.1 Biparietal Diameter 5.5 cm 300
1.8.1.2 Biparietal Diameter 5.3 cm 300
1.8.1.3 Biparietal Diameter 5.4 cm 300
1.8.1.3.1 Derivation Mean 300
1.8.1.4 Gestational Age 190 d 5008
1.8.1.4.1 Equation Jeanty, 1982 5008
1.8.1.4.2 5th Percentile Value of population 131 d 5008
1.8.1.4.3 95th Percentile Value of population 173 d 5008
1.8.2 Biometry Group 5008
1.8.2.1 Occipital-Frontal Diameter 18.1 cm 300
1.8.3 Biometry Group 5008
1.8.3.1 Head Circumference 34.3 cm 300
1.8.3.1.1 Derivation Estimated 300
1.8.4 Biometry Group 5008
1.8.4.1 Abdominal Circumference 34.9 cm 300
1.8.4.2 Abdominal Circumference 34.3 cm 300
1.8.4.3 Abdominal Circumference 34.3 cm 300
1.8.4.4 Abdominal Circumference 34.5 cm 300
1.8.4.4.1 Derivation Mean 300
1.8.4.5 Gestational Age 190 d 5008
1.8.4.5.1 Equation Hadlock, 1984 5008
1.8.4.5.2 2 Sigma Lower Value of population 184 d 5008
1.8.4.5.3 2 Sigma Upper Value of population 196 d 5008
1.8.5 Biometry Group 5008
1.8.5.1 Femur Length 4.5 cm 300
1.8.5.n 300

This example shows measurements and with percentile ranking.

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.8 Fetal Biometry 5005
1.8.1 Biometry Group 5008
1.8.1.1 Biparietal Diameter 5.5 cm 300
1.8.1.2 Biparietal Diameter 5.3 cm 300
1.8.1.3 Biparietal Diameter 5.4 cm 300
1.8.1.3.1 Derivation Mean 300
1.8.1.4 Growth Percentile Rank 63 % 5008
1.8.1.4.1 Equation BPD, Jeanty 1982 5008
1.8.2 Biometry Group 5008
1.8.2.n 300

Example 7: Amniotic Sac

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.6 Findings 5010
1.6.1 Finding Site Amniotic Sac 5010
1.6.2 Amniotic Fluid Index 11 cm 300
1.6.3 First Quadrant Diameter 10 cm 300
1.6.4 Second Quadrant Diameter 12 cm 300
1.6.5 Third Quadrant Diameter 11 cm 300
1.6.6 Fourth Quadrant Diameter 12 cm 300

Example 8: OB-GYN Ovaries

The content structure in the example below conforms to TID 5012. The example shows the volume derived from three perpendicular diameters.

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Figure I.8-1 Ovaries Example

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.9 Findings 5012
1.9.1 Finding Site Ovary 5012
1.9.2 Ovary 5016
1.9.2.1 Left Ovary Volume 6 cm3 300
1.9.2.2 Left Ovary Length 3 cm 300
1.9.2.3 Left Ovary Length 3 cm 300
1.9.2.4 Left Ovary Length 3 cm 300
1.9.2.4.1 Derivation Mean 300
1.9.2.5 Left Ovary Width 2 cm 300
1.9.2.5.1 Derivation Mean 300
1.9.2.6 Left Ovary Height 2 cm 300
1.9.2.6.1 Derivation Mean 300
1.9.3 Ovary 5016
1.9.3.1 RIght Ovary Volume 7 cm3 300
1.9.3.2 300

Example 9: OB-GYN Follicles

The content structure in the example below conforms to TID 5013. It uses multiple measurements and derived averages for each of the perpendicular diameters.

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Figure I.8-2 Follicles Example

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n …. 5000
1.8 Findings 5013
1.8.1 Finding Site Ovarian Follicle 5013
1.8.2 Laterality Right 5013
1.8.3 Number of follicles in right ovary 2 5013
1.8.4 Measurement Group 5014
1.8.4.1 Identifier #1 5014
1.8.4.2 Volume 3 cm3 300
1.8.4.3 Follicle Diameter 15 mm 300
1.8.4.4 Follicle Diameter 13 mm 300
1.8.4.5 Follicle Diameter 14 mm 300
1.8.4.5.1 Derivation Mean 300
1.8.5 Measurement Group 5014
1.8.5.1 Identifier #2 5014
1.8.5.2 Volume 4 cm3 300
1.8.5.3 Follicle Diameter 18 mm 300
1.9 Findings 5013
1.9.1 Finding Site Ovarian Follicle 5013
1.9.2 Laterality Left 5013
1.9.3 Number of follicles in left ovary 1 5013
1.9.4 Follicle Measurement Group 5014
1.9.4.1 Identifier #1 5014
1.9.4.2 Volume 3 cm3 300
1.9.4.3 Follicle Diameter 15 mm 300

Example 10: Pelvis and Uterus

Nest Code Meaning of Concept Name Code Meaning or Example Value TID
1 OB-GYN Ultrasound Procedure Report 5000
1.n ….
1.9 Pelvis and Uterus 5015
1.9.1 Uterus 5016
1.9.1.1 Uterus Volume 136 cm3 300
1.9.1.2 Uterus Length 9.5 cm 300
1.9.1.3 Uterus Width 5.9 cm 300
1.9.1.4 Uterus Height 4.2 cm 300
1.9.2 Endometrium Thickness 4 mm 5015
1.9.3 Cervix Length 5.3 cm 5015