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Page 196​ DICOM PS3.17 2020a - Explanatory Information​

Table Q.2-1. Breast Image Report Content for Example 1​

Node​

CodeMeaningofConceptName​ Code Meaning or Example Value​

TID/CID​

1​

Breast Imaging Report​

 

TID 4200​

1.1​

Language of Content Item and​

English​

TID 1204​

 

Descendants​

 

 

1.2​

Narrative Summary​

 

TID 4202​

1.2.1​

Procedure reported​

 

TID 4202​

 

 

 

CID 6052​

1.2.1.1​

Procedure reported​

Film screen mammography, both breasts.​

TID 4202​

 

 

 

CID 6053​

1.2.2​

Reason for procedure​

 

TID 4202​

 

 

 

CID 6052​

1.2.2.1​

Reason for procedure​

Screening​

TID 4202​

 

 

 

CID 6053​

1.2.3​

Findings​

 

TID 4202​

 

 

 

CID 6052​

1.2.3.1​

Finding​

Comparison was made to exam from​

TID 4202​

 

 

11/14/2001.Thebreastsareheterogeneously​

 

 

dense. This may lower the sensitivity of​

CID 6053​

 

 

mammography. No significant masses,​

 

 

 

calcifications, or other abnormalities are​

 

 

 

present. There is no significant change from​

 

 

the prior exam.​

 

1.2.4​

Impressions​

 

TID 4202​

 

 

 

CID 6052​

1.2.4.1​

Impression​

BI-RADS® Category 1: Negative.​

TID 4202​

 

 

Recommend normal interval follow-up in 12​

 

 

months.​

CID 6053​

Q.2.2 Example 2: Screening Mammogram With Negative Findings​

Ascreeningmammographycase,i.e.,therearetypicallyfourfilmsandnosuspiciousabnormalities.Theresultisanegativemammogram​ with basic reporting. This example illustrates a report encoded as narrative text with minimal supplementary data, and follows BI-​ RADS® and MQSA:​

Example Q.2-2. Report Sample: Narrative Text with Minimal Supplementary Data​

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Comparison to previous exams

- Standard -​

DICOM PS3.17 2020a - Explanatory Information​

Page 197​

Comparison was made to exam from 11/14/2001.

Breast composition

The breasts are heterogeneously dense. This may lower the sensitivity of mammography.

Findings

No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

Impressions

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

Overall Assessment

Negative

Table Q.2-2. Breast Imaging Report Content for Example 2​

Node​

Code Meaning of Concept Name​Code Meaning or Example Value​

TID/CID​

1​

Breast Imaging Report​

 

TID 4200​

 

1.1​

Language of Content Item and​

English​

TID 1204​

 

 

Descendants​

 

 

 

1.2​

Narrative Summary​

 

TID 4202​

 

1.2.1​

Procedure reported​

 

TID 4202​

 

 

 

 

CID 6052​

 

1.2.1.1​

Procedure reported​

Film screen mammography, both​

TID 4202​

 

 

 

breasts.​

CID 6053​

 

 

 

 

 

1.2.2​

Reason for procedure​

 

TID 4202​

 

 

 

 

CID 6052​

 

1.2.2.1​

Reason for procedure​

Screening​

TID 4202​

 

 

 

 

CID 6053​

 

1.2.3​

Comparison to previous exams​

 

TID 4202​

 

 

 

 

CID 6052​

 

1.2.3.1​

Comparison to previous exams​

Comparisonwasmadetoexamfrom​TID 4202​

 

 

 

11/14/2001.​

CID 6053​

 

 

 

 

 

1.2.4​

Breast composition​

 

TID 4202​

 

 

 

 

CID 6052​

 

1.2.4.1​

Breast composition​

The breasts are heterogeneously​

TID 4202​

 

 

 

dense.Thismaylowerthesensitivity​

 

 

 

of mammography.​

CID 6053​

 

1.2.5​

Findings​

 

TID 4202​

 

 

 

 

CID 6052​

 

- Standard -​

TID 4202​

Page 198​

 

DICOM PS3.17 2020a - Explanatory Information​

 

Node​

Code Meaning of Concept Name​Code Meaning or Example Value​

TID/CID​

1.2.5.1​

Finding​

Nosignificantmasses,calcifications,​TID 4202​

 

 

 

or other abnormalities are present.​

 

 

 

There is no significant change from​CID 6053​

 

 

 

the prior exam.​

 

1.2.6​ Impressions​

 

 

 

CID 6052​

1.2.6.1​

Impression​

BI-RADS® Category 1: Negative.​

TID 4202​

 

 

Recommend normal interval​

CID 6053​

 

 

follow-up in 12 months.​

1.2.7​

Overall Assessment​

 

TID 4202​

 

 

 

CID 6052​

1.2.7.1​

Overall Assessment​

Negative​

TID 4202​

 

 

 

CID 6053​

1.3​

Supplementary Data​

 

TID 4208​

1.3.1​

Procedure reported​

Film Screen Mammography​

TID 4201​

 

 

 

CID 6050​

1.3.1.1​

Laterality​

Both breasts​

TID 4201​

 

 

 

CID 6022​

1.3.1.2​

Reason for procedure​

Screening​

TID 4201​

 

 

 

CID 6051​

1.3.2​

Breast composition​

 

TID 4205​

1.3.2.1​

Breast composition​

Heterogeneously dense​

TID 4205​

 

 

 

CID 6000​

1.3.2.1.1​

Laterality​

Both breasts​

TID 4205​

 

 

 

CID 6022​

1.3.3​

Overall Assessment​

 

TID 4208​

1.3.3.1​

Assessment Category​

1 - Negative​

TID 4203​

 

 

 

CID 6026​

1.3.3.2​

Recommended Follow-up​

Normal interval follow-up​

TID 4203​

 

 

 

CID 6028​

Q.2.3 Example 3: Diagnostic Mammogram - Unilateral​

A diagnostic mammogram was prompted by a clinical finding. The result is a probably benign finding with a short interval follow-up​ of the left breast. This report provides the narrative text with more extensive supplementary data.​

Example Q.2-3. Report Sample: Narrative Text with More Extensive Supplementary Data​

Procedure reported

Film screen mammography, left breast.

- Standard -​

DICOM PS3.17 2020a - Explanatory Information​

Page 199​

Reason for procedure

Non-bloody discharge left breast.

Breast composition

The breast is almost entirely fat.

Findings

Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.

Impressions

BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.

Table Q.2-3. Breast Imaging Report Content for Example 3​

Node​

CodeMeaningofConceptName​ Code Meaning or Example Value​

TID/CID​

1​

Breast Imaging Report​

 

TID 4200​

1.1​

Language of Content Item and​

English​

TID 1204​

 

Descendants​

 

 

1.2​

Narrative Summary​

 

TID 4202​

1.2.1​

Procedure reported​

 

TID 4202​

 

 

 

CID 6052​

1.2.1.1​

Procedure reported​

Film screen mammography, left breast.​TID 4202​

 

 

 

CID 6053​

1.2.2​

Reason for procedure​

 

TID 4202​

 

 

 

CID 6052​

1.2.2.1​

Reason for procedure​

Non-bloody discharge left breast.​

TID 4202​

 

 

 

CID 6053​

1.2.3​

Breast composition​

 

TID 4202​

 

 

 

CID 6052​

1.2.3.1​

Breast composition​

The breast is almost entirely fat.​

TID 4202​

 

 

 

CID 6053​

1.2.4​

Findings​

 

TID 4202​

 

 

 

CID 6052​

1.2.4.1​

Finding​

Film screen mammograms were​

TID 4202​

 

 

performed. There are heterogeneous​

 

CID 6053​ calcificationsregionallydistributedinthe​

1 o'clock upper outer quadrant, anterior​ region of the left breast. There is an​ increase in the number of calcifications​ from the prior exam.​

- Standard -​

Page 200​

DICOM PS3.17 2020a - Explanatory Information​

 

Node​

CodeMeaningofConceptName​ Code Meaning or Example Value​

TID/CID​

1.2.5​

Impressions​

 

TID 4202​

 

 

 

CID 6052​

1.2.5.1​

Impression​

BI-RADS®Category3:ProbablyBenign​TID 4202​

 

 

Finding. Short interval follow-up of the​

 

 

 

CID 6053​

 

 

leftbreastisrecommendedin6months.​

1.3​

Supplementary Data​

 

TID 4208​

1.3.1​

Procedure reported​

Film Screen Mammography​

TID 4201​

 

 

 

CID 6050​

1.3.1.1​

Laterality​

Left breast​

TID 4201​

 

 

 

CID 6022​

1.3.1.2​

Reason for procedure​

Clinical Finding​

TID 4201​

 

 

 

CID 6051​

1.3.1.2.1​

Clinical Finding​

Non-bloody discharge​

TID 4201​

 

 

 

CID 6055​

1.3.1.2.1.1​

Laterality​

Left breast​

TID 4201​

 

 

 

CID 6022​

1.3.2​

Breast composition​

 

TID 4205​

1.3.2.1​

Breast composition​

Almost entirely fat​

TID 4205​

 

 

 

CID 6000​

1.3.2.1.1​

Laterality​

Left breast​

TID 4205​

 

 

 

CID 6022​

1.3.3​

Findings​

 

TID 4206​

1.3.3.1​

Finding​

Calcification of breast​

TID 4206​

 

 

 

CID 6054​

1.3.3.1.1​

Assessment Category​

3 - Probably Benign Finding - short​

TID 4203​

 

 

interval follow-up​

CID 6026​

 

 

 

1.3.3.1.2​

Recommended Follow-up​

Follow-upatshortinterval(1-11months)​TID 4203​

 

 

 

CID 6028​

1.3.3.1.2.1​

Laterality​

Left breast​

TID 4203​

 

 

 

CID 6022​

1.3.3.1.2.2​

RecommendedFollow-upInterval​6 months​

TID 4203​

 

 

 

CID 6046​

1.3.3.1.3​

Clockface or region​

1 o'clock position​

TID 4206​

 

 

 

CID 6018​

1.3.3.1.4​

Quadrant location​

Upper outer quadrant of breast​

TID 4206​

 

 

 

CID 6020​

- Standard -​

Источник: https://studfile.net/preview/14585770/

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