DICOM PS3.17 2019c - Explanatory Information

Q.2.2 Example 2: 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 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

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 Descendants

English

TID 1204

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

Comparison to previous exams

TID 4202

CID 6052

1.2.3.1

Comparison to previous exams

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

TID 4202

CID 6053

1.2.4

Breast composition

TID 4202

CID 6052

1.2.4.1

Breast composition

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

TID 4202

CID 6053

1.2.5

Findings

TID 4202

CID 6052

1.2.5.1

Finding

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

TID 4202

CID 6053

1.2.6

Impressions

TID 4202

CID 6052

1.2.6.1

Impression

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

TID 4202

CID 6053

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


DICOM PS3.17 2019c - Explanatory Information