DICOM PS3.17 2020b - Explanatory Information

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.

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

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, 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 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.

TID 4202

CID 6053

1.2.5

Impressions

TID 4202

CID 6052

1.2.5.1

Impression

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

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

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 interval follow-up

TID 4203

CID 6026

1.3.3.1.2

Recommended Follow-up

Follow-up at short interval (1-11 months)

TID 4203

CID 6028

1.3.3.1.2.1

Laterality

Left breast

TID 4203

CID 6022

1.3.3.1.2.2

Recommended Follow-up Interval

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

1.3.3.1.5

Depth

Anterior

TID 4206

CID 6024

1.3.3.1.6

Calcification Type

Heterogeneous calcification

TID 4206

CID 6010

1.3.3.1.7

Calcification Distribution

Regional calcification distribution

TID 4206

CID 6012

1.3.3.1.8

Change since last mammogram

Increase in number of calcifications

TID 4206

CID 6002


DICOM PS3.17 2020b - Explanatory Information