Q.2.1 Example 1: Screening Mammogram with Negative Findings

A screening mammography case, i.e., there are typically four films and no suspicious abnormalities. The result is a negative mammogram with basic reporting. This example illustrates a report encoded as narrative text only:

Report Sample:

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Findings

Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

Impressions

BI-RADSĀ® Category 1: Negative. Recommend normal interval follow-up in 12 months

TABLE Q.2-1: Breast Image Report Content for Example 1

Node Code Meaning of Concept Name Code Meaning or Example Value TID/CID
1 Breast Imaging Report 4200
1.1 Language of Content Item and Descendants English 1204
1.2 Narrative Summary 4202
1.2.1 Procedure reported 4202/6052
1.2.1.1 Procedure reported Film screen mammography, both breasts. 4202/6053
1.2.2 Reason for procedure 4202/6052
1.2.2.1 Reason for procedure Screening 4202/6053
1.2.3 Findings 4202/6052
1.2.3.1 Finding Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam. 4202/6053
1.2.4 Impressions 4202/6052
1.2.4.1 Impression BI-RADSĀ® Category 1: Negative. Recommend normal interval follow-up in 12 months. 4202/6053