Файл: part16.pdf

Notice and Disclaimer ...........................................................................................................................................

61​

Foreword ............................................................................................................................................................

63​

1. Scope and Field of Application .............................................................................................................................

65​

2. Normative References .......................................................................................................................................

67​

3. Definitions .......................................................................................................................................................

73​

4. Symbols and Abbreviations .................................................................................................................................

75​

5. Conventions .....................................................................................................................................................

77​

6. Form of Template Specifications ..........................................................................................................................

79​

6.1. Template Table Field Definition .....................................................................................................................

80​

6.1.1. Row Number .......................................................................................................................................

81​

6.1.2. Nesting Level (NL) ...............................................................................................................................

81​

6.1.3. Relationship With Source Content Item (Parent) .........................................................................................

81​

6.1.4. Value Type (VT) ..................................................................................................................................

82​

6.1.5. Concept Name ....................................................................................................................................

82​

6.1.6. Value Multiplicity (VM) ...........................................................................................................................

82​

6.1.7. Requirement Type ................................................................................................................................

82​

6.1.8. Condition ............................................................................................................................................

83​

6.1.9. Value Set Constraint .............................................................................................................................

83​

6.1.9.1. NUM Units Constraint .....................................................................................................................

83​

6.1.9.2. CONTAINER Continuation Flag Constraint .........................................................................................

83​

6.1.9.3. SCOORD Graphic Type Constraint ...................................................................................................

84​

6.2. Special Conventions for Template Tables ........................................................................................................

84​

6.2.1. Multiple Value Sets Depending On Different Conditions ...............................................................................

84​

6.2.2. Target Content Items of Relationships ......................................................................................................

84​

6.2.3. Inclusion of Templates ..........................................................................................................................

84​

6.2.3.1. Template Parameters .....................................................................................................................

84​

6.2.4. Post-coordinated Codes and Has Concept Modifier Relationship ...................................................................

85​

6.2.5. Extension of Templates .........................................................................................................................

85​

7. DCMR Context Group Specifications .....................................................................................................................

87​

7.1. Context Group Table Field Definition ..............................................................................................................

87​

7.2. Special Conventions for Context Group Tables .................................................................................................

88​

7.2.1. Include Context Group ..........................................................................................................................

88​

7.2.2. Units of Measurement ...........................................................................................................................

88​

7.2.3. Extension of Context Groups ..................................................................................................................

89​

8. Coding Schemes ..............................................................................................................................................

91​

8.1. SNOMED CT ...........................................................................................................................................

101​

8.1.1. Use of SNOMED Anatomic Concepts .....................................................................................................

102​

8.2. ISO_OID .................................................................................................................................................

102​

8.3. Retired Codes and Expected Behavior ..........................................................................................................

102​

A. Structured Reporting Templates (Normative) ........................................................................................................

103​

General Templates. ........................................................................................................................................ 103​

TID 300. Measurement ................................................................................................................................

103​

TID 310. Measurement Properties ..................................................................................................................

105​

TID 311. Measurement Statistical Properties ....................................................................................................

106​

TID 312. Normal Range Properties .................................................................................................................

106​

TID 315. Equation or Table ...........................................................................................................................

107​

TID 320. Image or Spatial Coordinates ............................................................................................................

107​

TID 321. Waveform or Temporal Coordinates ...................................................................................................

108​

TID 350. References to Supporting Evidence ...................................................................................................

108​

TID 351. Previous Reports ............................................................................................................................

109​

TID 400. Reference Location .........................................................................................................................

109​

TID 1000. Quotation ....................................................................................................................................

109​

TID 1001. Observation Context ......................................................................................................................

110​

TID 1002. Observer Context .........................................................................................................................

111​

TID 1003. Person Observer Identifying Attributes ..............................................................................................

111​

TID 1004. Device Observer Identifying Attributes ...............................................................................................

112​

TID 1005. Procedure Context ........................................................................................................................

113​

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TID 1006. Subject Context ............................................................................................................................

114​

TID 1007. Subject Context, Patient .................................................................................................................

115​

TID 1008. Subject Context, Fetus

...................................................................................................................

116​

TID 1009. Subject Context, Specimen .............................................................................................................

116​

TID 1010. Subject Context, Device .................................................................................................................

117​

TID 1020. Person Participant ........................................................................................................................

117​

TID 1021. Device Participant .........................................................................................................................

118​

TID 1200. Language Designation

...................................................................................................................

119​

TID 1201. Language of Value ........................................................................................................................

119​

TID 1202. Language of Name and Value .........................................................................................................

120​

TID 1204. Language of Content Item and Descendants ......................................................................................

120​

TID 1210. Equivalent Meaning(s) of Concept Name ...........................................................................................

120​

TID 1211. Equivalent Meaning(s) of Value .......................................................................................................

121​

TID 1350. Negation Modifier, Presence of Finding .............................................................................................

122​

TID 1400. Linear Measurement .....................................................................................................................

123​

TID 1401. Area Measurement .......................................................................................................................

123​

TID 1402. Volume Measurement ....................................................................................................................

124​

TID 1404. Numeric Measurement

...................................................................................................................

125​

TID 1406. Three Dimensional Linear Measurement ...........................................................................................

126​

TID 1410. Planar ROI Measurements and Qualitative Evaluations ........................................................................

126​

TID 1411. Volumetric ROI Measurements and Qualitative Evaluations ...................................................................

129​

TID 1419. ROI Measurements .......................................................................................................................

133​

TID 1420. Measurements Derived From Multiple ROI Measurements ....................................................................

135​

TID 1500. Measurement Report .....................................................................................................................

138​

TID 1501. Measurement and Qualitative Evaluation Group ..................................................................................

141​

TID 1502. Time Point Context .......................................................................................................................

144​

TID 1600. Image Library ...............................................................................................................................

145​

TID 1601. Image Library Entry .......................................................................................................................

145​

TID 1602. Image Library Entry Descriptors .......................................................................................................

146​

TID 1603. Image Library Entry Descriptors for Projection Radiography ..................................................................

147​

TID 1604. Image Library Entry Descriptors for Cross-Sectional Modalities ..............................................................

148​

TID 1605. Image Library Entry Descriptors for CT ..............................................................................................

149​

TID 1606. Image Library Entry Descriptors for MR .............................................................................................

149​

TID 1607. Image Library Entry Descriptors for PET ............................................................................................

150​

TID 2000. Basic Diagnostic Imaging Report .....................................................................................................

151​

TID 2001. Basic Diagnostic Imaging Report Observations ...................................................................................

152​

TID 2002. Report Narrative ...........................................................................................................................

153​

TID 2005. Transcribed Diagnostic Imaging Report .............................................................................................

153​

TID 2006. Imaging Report With Conditional Radiation Exposure and Protection Information .......................................

154​

TID 2007. Imaging Procedure Description ........................................................................................................

156​

TID 2008. Radiation Exposure and Protection Information ...................................................................................

157​

TID 2010. Key Object Selection .....................................................................................................................

157​

TID 2020. Spectacle Prescription Report .........................................................................................................

159​

TID 2021. Template for Spectacle Prescription Details .......................................................................................

159​

TID 2100. Macular Grid Thickness and Volume Report .......................................................................................

160​

TID 2101. Macular Grid Thickness and Volume Measurement .............................................................................

160​

TID 2102. Quality Rating Identification ............................................................................................................

162​

Procedure Log IOD Templates. ......................................................................................................................... 163​

TID 3001. Procedure Log .............................................................................................................................

163​

TID 3010. Log Entry Qualifiers .......................................................................................................................

164​

TID 3100. Procedure Action ..........................................................................................................................

165​

TID 3101. Image Acquisition .........................................................................................................................

166​

TID 3102. Waveform Acquisition ....................................................................................................................

167​

TID 3103. Referenced Object ........................................................................................................................

167​

TID 3104. Consumables ...............................................................................................................................

168​

TID 3105. Lesion Identification and Properties ..................................................................................................

168​

TID 3106. Drugs/Contrast Administered ..........................................................................................................

169​

TID 3107. Device Used ................................................................................................................................

170​

TID 3108. Intervention .................................................................................................................................

170​

TID 3109. Measurements .............................................................................................................................

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TID 3110. Impressions or Findings .................................................................................................................

172​

TID 3111. Percutaneous Entry .......................................................................................................................

172​

TID 3112. Specimen Obtained .......................................................................................................................

173​

TID 3113. Patient Support ............................................................................................................................

173​

TID 3114. Patient Assessment ......................................................................................................................

174​

TID 3115. ECG ST Assessment .....................................................................................................................

176​

Quantitative Ventricular Analysis Report SR IOD Templates. .................................................................................. 176​

TID 3202. Ventricular Analysis .......................................................................................................................

176​

TID 3205. Calibration ...................................................................................................................................

178​

TID 3206. VA Main Results ...........................................................................................................................

179​

TID 3207. AA Main Results ...........................................................................................................................

183​

TID 3208. Frame-to-Frame Results ................................................................................................................

183​

TID 3209. Centerline Wall Motion ...................................................................................................................

184​

TID 3210. Radial Based Wall Motion ...............................................................................................................

186​

TID 3211. Landmark Based Wall Motion ..........................................................................................................

187​

Quantitative Arterial Analysis Report SR IOD Templates. ....................................................................................... 187​

TID 3213. Quantitative Arterial Analysis ...........................................................................................................

188​

TID 3214. Analyzed Segment ........................................................................................................................

189​

TID 3215. Angiographic Lesion Analysis ..........................................................................................................

191​

TID 3216. Stenotic Flow Reserve ...................................................................................................................

195​

TID 3217. Sub-segmental Data ......................................................................................................................

196​

TID 3218. Position in Arterial Segment ............................................................................................................

196​

TID 3219. Segment Values ...........................................................................................................................

197​

IVUS Report Templates. .................................................................................................................................. 198​

TID 3250. IVUS Report ................................................................................................................................

199​

TID 3251. IVUS Vessel ................................................................................................................................

199​

TID 3252. IVUS Lesion ................................................................................................................................

200​

TID 3253. IVUS Measurements .....................................................................................................................

201​

TID 3254. IVUS Qualitative Assessments ........................................................................................................

202​

TID 3255. IVUS Volume Measurement ............................................................................................................

203​

Stress Testing Report Templates. ..................................................................................................................... 204​

TID 3300. Stress Testing Report ....................................................................................................................

204​

TID 3301. Stress Test Procedure Description ...................................................................................................

204​

TID 3303. Stress Test Phase Data .................................................................................................................

206​

TID 3304. Stress Test Measurement Group .....................................................................................................

206​

TID 3307. NM/PET Perfusion Measurement Group ............................................................................................

209​

TID 3309. Stress Echo Measurement Group ....................................................................................................

211​

TID 3311. Stress Test Summary ....................................................................................................................

212​

TID 3312. Physiological Summary ..................................................................................................................

213​

TID 3313. Stress ECG Summary ...................................................................................................................

214​

TID 3317. Stress Imaging Summary ...............................................................................................................

216​

TID 3318. Comparison to Prior Stress Exam ....................................................................................................

217​

TID 3320. Conclusions and Recommendations .................................................................................................

218​

Hemodynamics Report Templates. .................................................................................................................... 218​

TID 3500. Hemodynamics Report ..................................................................................................................

219​

TID 3501. Hemodynamics Measurement Group ................................................................................................

220​

TID 3504. Arterial Pressure Measurement .......................................................................................................

221​

TID 3505. Atrial Pressure Measurement ..........................................................................................................

221​

TID 3506. Venous Pressure Measurement .......................................................................................................

222​

TID 3507. Ventricular Pressure Measurement ...................................................................................................

223​

TID 3508. Gradient Measurement ..................................................................................................................

224​

TID 3509. Blood Velocity Measurement ...........................................................................................................

225​

TID 3510. Vital Signs ...................................................................................................................................

226​

TID 3515. Cardiac Output Measurement by Indicator Dilution ..............................................................................

227​

TID 3516. Blood Lab Measurements ...............................................................................................................

227​

TID 3520. Hemodynamic Clinical Context ........................................................................................................

228​

TID 3521. Relative Time ...............................................................................................................................

230​

TID 3530. Hemodynamic Acquisition Context ...................................................................................................

230​

TID 3550. Pressure Waveform Measurements ..................................................................................................

231​

TID 3560. Derived Hemodynamic Measurements ..............................................................................................

232​

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TID 3570. Summary, Hemodynamics ..............................................................................................................

236​

TID 3601. Procedure Context ........................................................................................................................

236​

TID 3602. Cardiovascular Patient Characteristics ..............................................................................................

237​

TID 3603. Procedure Environmental Characteristics ..........................................................................................

238​

ECG Report Templates. .................................................................................................................................. 238​

TID 3700. ECG Report .................................................................................................................................

238​

TID 3701. Clinical Context, ECG (Retired) .......................................................................................................

239​

TID 3702. Prior ECG Exam ...........................................................................................................................

239​

TID 3704. Patient Characteristics for ECG .......................................................................................................

240​

TID 3708. ECG Waveform Information ............................................................................................................

240​

TID 3713. ECG Global Measurements ............................................................................................................

241​

TID 3714. ECG Lead Measurements ..............................................................................................................

242​

TID 3715. ECG Measurement Source .............................................................................................................

243​

TID 3717. ECG Qualitative Analysis ...............................................................................................................

243​

TID 3718. ECG Interpretive Statement (Retired) ................................................................................................

244​

TID 3719. Summary, ECG ............................................................................................................................

244​

Cath Lab Clinical Report Templates. .................................................................................................................. 244​

TID 3800. Cardiac Catheterization Report Root .................................................................................................

245​

TID 3802. Cardiovascular Patient History .........................................................................................................

246​

TID 3803. Patient Presentation, Cath ..............................................................................................................

249​

TID 3806. Cath Procedure ............................................................................................................................

250​

TID 3807. Percutaneous Coronary Intervention Procedure ..................................................................................

251​

TID 3808. Lesion Intervention Information ........................................................................................................

252​

TID 3809. Other Interventional Procedures ......................................................................................................

253​

TID 3810. Cardiac Catheterization Findings .....................................................................................................

254​

TID 3812. Hemodynamic Findings ..................................................................................................................

255​

TID 3814. Left Ventriculography Findings ........................................................................................................

255​

TID 3815. Right Ventriculography Findings ......................................................................................................

257​

TID 3816. Ventricular Assessment .................................................................................................................

257​

TID 3817. Coronary Arteriography Findings ......................................................................................................

258​

TID 3818. Other Cardiographic Findings ..........................................................................................................

259​

TID 3819. Common Findings .........................................................................................................................

259​

TID 3820. Adverse Outcomes, Cath ...............................................................................................................

259​

TID 3824. Summary, Cath ............................................................................................................................

260​

TID 3828. Discharge Summary, Cath ..............................................................................................................

261​

TID 3829. Problem Properties .......................................................................................................................

261​

TID 3830. Procedure Properties .....................................................................................................................

262​

TID 3831. Medical Device Use ......................................................................................................................

263​

CT/MR Cardiovascular Analysis Report Templates. .............................................................................................. 264​

TID 3900. CT/MR Cardiovascular Analysis Report .............................................................................................

264​

TID 3901. Procedure Summary .....................................................................................................................

264​

TID 3902. Vascular Analysis .........................................................................................................................

265​

TID 3905. Calcium Scoring Results ................................................................................................................

270​

TID 3906. Vascular Section Measurements ......................................................................................................

271​

TID 3907. Vessel Measurements

...................................................................................................................

272​

TID 3908. Vascular Lesion ............................................................................................................................

273​

TID 3909. Best Illustration of Findings .............................................................................................................

275​

TID 3910. Flow Quantification .......................................................................................................................

275​

TID 3911. Plaque Properties .........................................................................................................................

277​

TID 3912. Stenosis Properties .......................................................................................................................

278​

TID 3913. Aneurysm Properties .....................................................................................................................

279​

TID 3914. Arterial Dissection Properties ..........................................................................................................

279​

TID 3915. Vascular Occlusion Properties .........................................................................................................

280​

TID 3916. Stent Properties ...........................................................................................................................

280​

TID 3917. Aneurysm Measurements ...............................................................................................................

281​

TID 3920. Ventricular Analysis .......................................................................................................................

282​

TID 3921. Ventricular Measurements ..............................................................................................................

282​

TID 3922. Absolute Values of Ventricular Measurements ....................................................................................

283​

TID 3923. BSA-Normalized Ventricular Measurements .......................................................................................

284​

TID 3924. Heart Rate-Normalized Ventricular Measurements ..............................................................................

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TID 3925. Ventricular Thickening Analysis .......................................................................................................

287​

TID 3926. Myocardial Perfusion Analysis .........................................................................................................

288​

TID 3927. Report Summary ..........................................................................................................................

290​

TID 3929. Cardiovascular Analysis Observation Context .....................................................................................

290​

TID 3990. Two Dimensional Measurement Graph ..............................................................................................

291​

Mammography CAD SR IOD Templates. ............................................................................................................ 292​

TID 4000. Mammography CAD Document Root ................................................................................................

292​

TID 4001. Mammography CAD Overall Impression/Recommendation ....................................................................

294​

TID 4002. Mammography CAD Impression/Recommendation Body ......................................................................

295​

TID 4003. Mammography CAD Individual Impression/Recommendation ................................................................

296​

TID 4004. Mammography CAD Composite Feature ...........................................................................................

297​

TID 4005. Mammography CAD Composite Feature Body ....................................................................................

298​

TID 4006. Mammography CAD Single Image Finding .........................................................................................

301​

TID 4007. Mammography CAD Breast Composition ...........................................................................................

304​

TID 4008. Mammography CAD Breast Geometry ..............................................................................................

304​

TID 4009. Mammography CAD Individual Calcification .......................................................................................

305​

TID 4010. Mammography CAD Calcification Cluster ..........................................................................................

305​

TID 4011. Mammography CAD Density ...........................................................................................................

306​

TID 4012. Mammography CAD Non-lesion .......................................................................................................

307​

TID 4013. Mammography CAD Selected Region ...............................................................................................

307​

TID 4014. CAD Image Quality .......................................................................................................................

308​

TID 4015. CAD Detections Performed .............................................................................................................

309​

TID 4016. CAD Analyses Performed ...............................................................................................................

309​

TID 4017. CAD Detection Performed ..............................................................................................................

310​

TID 4018. CAD Analysis Performed ................................................................................................................

311​

TID 4019. Algorithm Identification ...................................................................................................................

312​

TID 4020. CAD Image Library Entry ................................................................................................................

313​

TID 4021. Mammography CAD Geometry ........................................................................................................

316​

TID 4022. CAD Observation Context ..............................................................................................................

316​

TID 4023. CAD Operating Points ...................................................................................................................

317​

Chest CAD SR IOD Templates. ........................................................................................................................ 318​

TID 4100. Chest CAD Document Root ............................................................................................................

318​

TID 4101. Chest CAD Findings Summary ........................................................................................................

320​

TID 4102. Chest CAD Composite Feature ........................................................................................................

320​

TID 4103. Chest CAD Composite Feature Body ................................................................................................

322​

TID 4104. Chest CAD Single Image Finding .....................................................................................................

323​

TID 4105. Chest CAD Descriptors ..................................................................................................................

326​

TID 4106. Response Evaluation .....................................................................................................................

327​

TID 4107. Chest CAD Geometry ....................................................................................................................

327​

TID 4108. Tracking Identifier .........................................................................................................................

328​

Colon CAD SR IOD Templates. ........................................................................................................................ 328​

TID 4120. Colon CAD Document Root ............................................................................................................

329​

TID 4121. Colon CAD Findings Summary ........................................................................................................

330​

TID 4122. CAD Common Image Properties Entry ..............................................................................................

331​

TID 4125. Colon CAD Composite Feature ........................................................................................................

332​

TID 4126. Colon CAD Composite Feature Body ................................................................................................

333​

TID 4127. Colon CAD Single Image Finding .....................................................................................................

334​

TID 4128. Colon CAD Descriptors ..................................................................................................................

336​

TID 4129. Colon CAD Geometry ....................................................................................................................

337​

Breast Imaging Report Templates. .................................................................................................................... 338​

TID 4200. Breast Imaging Report ...................................................................................................................

339​

TID 4201. Breast Imaging Procedure Reported .................................................................................................

340​

TID 4202. Breast Imaging Report Narrative ......................................................................................................

341​

TID 4203. Breast Imaging Assessment ............................................................................................................

341​

TID 4204. Breast Imaging Report Intervention Section ........................................................................................

342​

TID 4205. Breast Composition Section ............................................................................................................

343​

TID 4206. Breast Imaging Report Finding Section .............................................................................................

344​

TID 4207. Breast Imaging Pathology Results ....................................................................................................

346​

TID 4208. Breast Imaging Report Supplementary Data .......................................................................................

347​

TID 4209. Breast Patient Characteristics .........................................................................................................

348​