DICOM PS3.17 2019b - Explanatory Information

Q.2 Breast Imaging Report Examples

The following are simple illustrations of encoding Mammography procedure based Breast Imaging Reports.

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:

Example Q.2-1. Report Sample: Narrative Text Only

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-RADS® 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

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

Findings

TID 4202

CID 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.

TID 4202

CID 6053

1.2.4

Impressions

TID 4202

CID 6052

1.2.4.1

Impression

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

TID 4202

CID 6053


DICOM PS3.17 2019b - Explanatory Information