Procedure Log IOD Templates

Procedure Log IOD Templates
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TID 3001 Procedure Log

The Procedure Log template is intended for the representation of reports or logs of time-stamped events occurring during an image-guided interventional or other procedure.

This Template does not require a particular ordering of the subsidiary Content Items.

Note

The Procedure Log IOD (PS3.3) requires ordering by Observation DateTime; thus log entries of different types (i.e., specified by different Rows in the Template) may appear in any order.
While this Template is extensible, the Procedure Log IOD forbids Container Content Items subsidiary to the top level Container.

Type:: Extensible
Order:: Non-Significant
Root:: Yes

Table TID 3001. Procedure Log

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	DCID 3400 “Procedure Log Titles”	1	M	Root node
2	>		INCLUDE	DTID 1002 “Observer Context”	1-n	M
3	>		INCLUDE	DTID 3601 “Procedure Context”	1	M
4	>	HAS ACQ CONTEXT	TEXT	EV (121121, DCM, "Room identification")	1	U
5	>	HAS ACQ CONTEXT	TEXT	EV (121122, DCM, "Equipment identification")	1-n	U
6	>	CONTAINS	TEXT	DCID 3401 “Types of Log Notes”	1-n	U
7	>>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
8	>	CONTAINS	CODE	EV (121123, DCM, "Patient Status or Event")	1-n	U	DCID 3402 “Patient Status and Events”
9	>>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
10	>	CONTAINS	PNAME	DCID 3404 “Staff Actions”	1-n	U
11	>>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
12	>	CONTAINS	TEXT	DCID 3427 “Equipment Events”	1-n	U	Equipment identifier
13	>>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
14	>	CONTAINS	INCLUDE	DTID 3100 “Procedure Action”	1-n	U
15	>	CONTAINS	INCLUDE	DTID 3101 “Image Acquisition”	1-n	U
16	>	CONTAINS	INCLUDE	DTID 3102 “Waveform Acquisition”	1-n	U
17	>	CONTAINS	INCLUDE	DTID 3103 “Referenced Object”	1-n	U
18	>	CONTAINS	INCLUDE	DTID 3104 “Consumables”	1-n	U
19	>	CONTAINS	INCLUDE	DTID 3105 “Lesion Identification and Properties”	1-n	U
20	>	CONTAINS	INCLUDE	DTID 3106 “Drugs/Contrast Administered”	1-n	U
21	>	CONTAINS	INCLUDE	DTID 3107 “Device Used”	1-n	U
22	>	CONTAINS	INCLUDE	DTID 3108 “Intervention”	1-n	U
23	>	CONTAINS	CODE	EV (DD-60002, SRT, "Complication of Procedure")	1-n	U	DCID 3413 “Adverse Outcomes”
24	>>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
25	>	CONTAINS	INCLUDE	DTID 3109 “Measurements”	1-n	U
26	>	CONTAINS	INCLUDE	DTID 3110 “Impressions or Findings”	1-n	U
27	>	CONTAINS	INCLUDE	DTID 3111 “Percutaneous Entry”	1-n	U
28	>	CONTAINS	INCLUDE	DTID 3112 “Specimen Obtained”	1-n	U
29	>	CONTAINS	INCLUDE	DTID 3113 “Patient Support”	1-n	U
30	>	CONTAINS	INCLUDE	DTID 3114 “Patient Assessment”	1-n	U
31	>	CONTAINS	INCLUDE	DTID 3115 “ECG ST Assessment”	1-n	U

Content Item Descriptions

Row 2	Includes TID 1002 “Observer Context”, which shall be used to record the identity of the person responsible for recording the log, as well as all other participants in the procedure, even though these personnel may not technically be "observers" of the Procedure Log. As participants in the procedure, they are potential sources for events and observations recorded in the Log. TID 1002 “Observer Context” allows the specification of the person's role in the organization (e.g., physician, nurse), as well as the role in the procedure (e.g., circulating, performing, etc.).
Row 5	Shall be used to record the identity of the major equipment used in the procedure.
Row 6	May be used to record any event not covered by a specific log entry template.

TID 3010 Log Entry Qualifiers

The Log Entry Qualifiers Template provides a common means for adding additional description to a procedure log content item. It allows identification of a source for the procedure log entry (other than the recording observer for the log as a whole), a free text comment, a link to a particular Procedure Action item, a link to a particular lesion, or the date/time of recording (if different than the time of the event occurrence recorded in the Observation DateTime of the parent content item).

Type:: Extensible
Order:: Significant

Table TID 3010. Log Entry Qualifiers

	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		INCLUDE	DTID 1000 “Quotation”	1	U
2	HAS PROPERTIES	TEXT	EV (121106, DCM, "Comment")	1	U
3	HAS OBS CONTEXT	TEXT	EV (121124, DCM, "Procedure Action ID")	1-n	U
4	HAS OBS CONTEXT	TEXT	EV (121151, DCM, "Lesion Identifier")	1-n	U	Up to 3 numeric characters
5	HAS OBS CONTEXT	DATETIME	EV (121125, DCM, "DateTime of Recording of Log Entry")	1	U
6	INFERRED FROM	IMAGE		1-n	U
7	INFERRED FROM	WAVEFORM		1-n	U
8	INFERRED FROM	COMPOSITE		1-n	U
9	HAS OBS CONTEXT	CODE	EV (121135, DCM, "Observation DateTime Qualifier")	1	U	DCID 3430 “DateTime Qualifiers”

Content Item Descriptions

Row 3	Procedure Action ID allows linking recorded events to a particular action, step, or phase of a procedure. See description for TID 3100 “Procedure Action”.
Row 4	Lesion Identifier is specified as a numeric text string, and allows linking recorded events to the diagnosis or therapy of particular lesion. See description for TID 3105 “Lesion Identification and Properties”.

TID 3100 Procedure Action

The Procedure Action Template is intended for the recording of the beginning or end of procedure steps or action items in a procedure. The level of granularity of the recorded events is not specified, and may vary between institutions, or even be at multiple levels within a single procedure log. There is no requirement for the real-world procedure step or action item recorded with this template to end before another one begins; there may be overlapping or simultaneous procedure steps or action items.

This log entry template may be used to record the start or stop of timers.

Other recorded events in the procedure may be linked to a particular step or action item by Procedure Action ID (see TID 3010 “Log Entry Qualifiers”).

Type:: Extensible
Order:: Significant

Table TID 3100. Procedure Action

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	DCID 3421 “Procedure Action”	1	M		BCID 3405 “Procedure Action Values”
2	>	HAS PROPERTIES	TEXT	EV (121124, DCM, "Procedure Action ID")	1	M
3	>	HAS PROPERTIES	PNAME	BCID 7453 “Performing Roles”	1-n	U
4	>	HAS PROPERTIES	NUM	EV (121128, DCM, "Procedure Action Duration")	1	U
5	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
6	>	HAS PROPERTIES	UIDREF	EV (121126, DCM, "Performed Procedure Step SOP Instance UID")	1	MC	IFF a Performed Procedure Step SOP Class is used to provide status of the Procedure Step
7	>	HAS PROPERTIES	UIDREF	EV (121127, DCM, "Performed Procedure Step SOP Class UID")	1	MC	IFF a Performed Procedure Step SOP Class is used to provide status of the Procedure Step

Content Item Descriptions

Row 2	The value of the Procedure Action ID shall be uniquely associated with the step or action within the context of the Study, and may be used to associate various Procedure Log entries with the step or action.
Row 3	May be used to record the identity of staff roles for the purpose of this Procedure Action, which may differ from their roles in the procedure as a whole.

TID 3101 Image Acquisition

The Image Acquisition Template allows recording of the essential parameters of a digital image acquired during the procedure.

Type:: Extensible
Order:: Significant

Table TID 3101. Image Acquisition

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			IMAGE	EV (121138, DCM, "Image Acquired")	1	M
2	>	HAS ACQ CONTEXT	UIDREF	EV (112002, DCM, "Series Instance UID")	1	M
3	>	HAS ACQ CONTEXT	CODE	EV (121139, DCM, "Modality")	1	M	DCID 29 “Acquisition Modality” Derived from referenced image SOP Instance attribute (0008,0060)
4	>	HAS PROPERTIES	NUM	EV (121140, DCM, "Number of Frames")	1	U
5	>	HAS PROPERTIES	TEXT	EV (121141, DCM, "Image Type")	1	U	From referenced image SOP Instance attribute (0008,0008)
6	>	HAS ACQ CONTEXT	NUM	EV (112011, DCM, "Positioner Primary Angle")	1	U	UNITS = EV (deg, UCUM, "deg")
7	>	HAS ACQ CONTEXT	NUM	EV (112012, DCM, "Positioner Secondary Angle")	1	U	UNITS = EV (deg, UCUM, "deg")
8	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3102 Waveform Acquisition

The Waveform Acquisition Template allows recording of the essential parameters of a digital waveform acquired during the procedure.

Type:: Extensible
Order:: Significant

Table TID 3102. Waveform Acquisition

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			WAVEFORM	EV (121143, DCM, "Waveform Acquired")	1	M
2	>	HAS ACQ CONTEXT	CODE	EV (121139, DCM, "Modality")	1	M	DCID 29 “Acquisition Modality” Derived from referenced waveform SOP Instance attribute (0008,0060)
3	>	HAS ACQ CONTEXT	NUM	EV (121142, DCM, "Acquisition Duration")	1	U
4	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3103 Referenced Object

The Referenced Object Template allows reference to measurement or report objects, such as prior medical reports, laboratory results, hemodynamic measurement reports, or quantitative analysis reports.

Type:: Extensible
Order:: Significant

Table TID 3103. Referenced Object

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			COMPOSITE	BCID 3407 “Purpose of Reference to Object”	1	M
2	>	HAS PROPERTIES	CODE	EV (121144, DCM, "Document Title")	1	MC	IFF Row 1 references an SR object	Root node concept of referenced SR object
3	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3104 Consumables

The Consumables Template allows recording of devices (e.g., catheters or stents), drugs, or contrast agents accessed in a procedure. This content item is directed towards inventory control and billing. The actual clinical use of the particular consumable is recorded using TID 3106 “Drugs/Contrast Administered” or TID 3107 “Device Used”.

This template allows recording both consumable retrieval from, and return to, inventory or stock, and disposal of used material. The quantity involved in each recorded transaction may be specified.

Type:: Extensible
Order:: Significant

Table TID 3104. Consumables

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	DCID 3408 “Actions With Consumables”	1	M	Vendor or local bar coded values
2	>	HAS PROPERTIES	TEXT	DCID 3426 “Consumables Parameters”	1-n	U
3	>	HAS PROPERTIES	NUM	EV (121146, DCM, "Quantity of Material")	1	U
4	>	HAS PROPERTIES	CODE	EV (121147, DCM, "Billing Code")	1	U	local billing codes
5	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3105 Lesion Identification and Properties

The Lesion Identification and Properties Template allows recording the identification of each lesion addressed in a procedure. The lesion identifier may be used to relate diagnostic or therapeutic actions with their target lesion (see Row 4 in TID 3010 “Log Entry Qualifiers”). This content item may include the initial visually estimated measurements of stenosis or TIMI flow; measured values from a quantitative measurement report may be referenced indirectly (through TID 3103 “Referenced Object”), or by quotation (TID 3109 “Measurements”). Subsequent (e.g., post-intervention) stenosis measurements may be encoded using TID 3109 “Measurements”, with the Lesion Identifier conveyed through its subsidiary TID 3010 “Log Entry Qualifiers” template.

Type:: Extensible
Order:: Significant

Table TID 3105. Lesion Identification and Properties

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			TEXT	EV (121151, DCM, "Lesion Identifier")	1	M		Up to 3 numeric characters
2	>	HAS PROPERTIES	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M		DCID 3604 “Arterial Lesion Locations”
3	>>	HAS CONCEPT MOD	CODE	EV (G-A1F8, SRT, "Topographical modifier")	1	U		DCID 3019 “Cardiovascular Anatomic Location Modifiers”
4	>	HAS PROPERTIES	CODE	EV (121153, DCM, "Lesion Risk")	1	U		DCID 3418 “Lesion Risk”
5	>	HAS PROPERTIES	NUM	EV (R-101BB, SRT, "Lumen Diameter Stenosis")	1	U		UNITS = EV (%, UCUM, "%")
6	>>	HAS CONCEPT MOD	CODE	EV (G-72BB, SRT, "Catheterization Procedure Phase")	1	M		EV (G-7293, SRT, "Baseline Phase")
7	>>	HAS CONCEPT MOD	CODE	EV (121401, DCM, "Derivation")	1	U		DCID 3745 “Calculation Method”
8	>	HAS PROPERTIES	CODE	EV (122109, DCM, "Baseline TIMI Flow")	1	UC	IFF Row 2 specifies a coronary artery	DCID 3713 “TIMI Flow Characteristics”
9	>	HAS PROPERTIES	CODE	EV (122131, DCM, "Degree of Thrombus")	1	U		DCID 3714 “Thrombus”
10	>	HAS PROPERTIES	CODE	EV (F-01740, SRT, "Lesion Margin Characteristics")	1	U		DCID 3715 “Lesion Margin”
11	>	HAS PROPERTIES	CODE	EV (122134, DCM, "Vessel Morphology")	1-n	U		DCID 3712 “Vessel Descriptors”
12	>	HAS PROPERTIES	CODE	EV (122132, DCM, "Severity of Calcification")	1	U		DCID 3716 “Severity”
13	>	HAS PROPERTIES	IMAGE	DT (121080, DCM, "Best illustration of finding")	1	U
14	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

Content Item Descriptions

Row 1

Lesion Identifier is specified as a numeric text string in order to facilitate transcoding to DICOM Attribute (0018,3105) Lesion Number and to formats for outcomes registries, such as the ACC National Cardiovascular Data Registry™.

TID 3106 Drugs/Contrast Administered

The Drugs/Contrast Administered Template allows the recording of the start or end of that type of event, together with its parameters. If start and end are represented by a single log entry (e.g., for an injection), the concept name "Drug/contrast administered" shall be used.

Type:: Extensible
Order:: Significant

Table TID 3106. Drugs/Contrast Administered

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	DCID 3409 “Administration of Drugs/Contrast”	1	M	BCID 10 “Interventional Drug” or BCID 12 “Radiographic Contrast Agent”
2	>	HAS PROPERTIES	TEXT	EV (121145, DCM, "Description of Material")	1	U
3	>	HAS PROPERTIES	CODE	EV (G-C340, SRT, "Route of administration")	1	U	BCID 11 “Route of Administration”
4	>	HAS PROPERTIES	NUM	DCID 3410 “Numeric Parameters of Drugs/Contrast”	1-n	U
5	>	HAS PROPERTIES	PNAME	EV (121152, DCM, "Person administering drug/contrast")	1	U
6	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3107 Device Used

The Device Used Template allows recording of the use of interventional diagnostic and therapeutic devices.

The identification of one device used to deploy another device (e.g., a balloon catheter to deploy a stent) may be described with two entries, with one identified as a deployment device in the Concept Modifier of Row 6 of this template, and linked by the same Procedure Action ID in the Log Entry Qualifiers of the included TID 3010 “Log Entry Qualifiers”.

Type:: Extensible
Order:: Significant

Table TID 3107. Device Used

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	DCID 3422 “Device Use Actions”	1	M	BCID 3429 “Catheterization Devices”
2	>	HAS PROPERTIES	CODE	EV (121150, DCM, "Device Code")	1-n	U	Vendor or local bar coded values
3	>	HAS PROPERTIES	TEXT	EV (121145, DCM, "Description of Material")	1	U
4	>	HAS PROPERTIES	NUM	DCID 3423 “Numeric Device Characteristics”	1-n	U
5	>	HAS PROPERTIES	CODE	EV (G-C0E9, SRT, "Procedure site")	1	U	BCID 3630 “Cardiovascular Anatomic Locations”
6	>	HAS CONCEPT MOD	CODE	EV (G-C0E8, SRT, "Has Intent")	1	U	DT (121155, DCM, "Deployment")
7	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3108 Intervention

The Intervention Template allows recording of interventions, including atherectomy, angioplasty, stent placement, brachytherapy, etc. The record may include reference to an image that documents the intervention.

Type:: Extensible
Order:: Significant

Table TID 3108. Intervention

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	EV (122090, DCM, "Intervention Action")	1	M		DCID 3412 “Intervention Actions and Status”
2	>	HAS PROPERTIES	CODE	EV (G-C0E9, SRT, "Procedure site")	1	M		DCID 3604 “Arterial Lesion Locations”
3	>>	HAS CONCEPT MOD	CODE	EV (G-A1F8, SRT, "Topographical modifier")	1	U		DCID 3019 “Cardiovascular Anatomic Location Modifiers”
4	>	HAS PROPERTIES	TEXT	EV (121154, DCM, "Intervention attempt identifier")	1	M		Up to 3 numeric characters
5	>	HAS PROPERTIES	CODE	EV (G-C50A, SRT, "Uses Equipment")	1-n	U		BCID 3411 “Intracoronary Devices”
6	>>	HAS CONCEPT MOD	CODE	EV (122111, DCM, "Primary Intervention Device")	1	MC	IF Device is Primary for this Lesion	DCID 230 “Yes-No”
7	>	HAS PROPERTIES	NUM	DCID 3425 “Intervention Parameters”	1-n	U
8	>	HAS PROPERTIES	IMAGE	BCID 7003 “Diagnostic Imaging Report Purposes of Reference”	1	U
9	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

Content Item Descriptions

Row 4

Intervention attempt Identifier is specified as a numeric text string, and shall be treated as the ordinal of the recorded attempted intervention within this procedure (i.e., "1" for the first attempted intervention, "2" for the second, etc.).

TID 3109 Measurements

The Measurements Template allows recording of significant measurements, such as vital signs, laboratory results, hemodynamic measurements, or quantitative analysis measurements. These measurements are often quoted from another source, which would be documented in the included TID 3010 “Log Entry Qualifiers”.

Type:: Extensible
Order:: Significant

Table TID 3109. Measurements

	NL	Rel with Parent	VT	Concept Name	VM	Req Type
1			NUM	No BCID	1	U
2	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
3	>	HAS PROPERTIES	INCLUDE	DTID 310 “Measurement Properties”	1	U
4			CODE	No BCID	1	U
5	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3110 Impressions or Findings

The Impressions or Findings Template allows the recording of unconfirmed (provisional) impressions or findings noted during the procedure. It is not intended to convey the Cath Lab Clinical Report (the formal report from the performing physician), although it may be used (like any Procedure Log entry) for the subsequent construction of the Cath Lab Clinical Report.

A finding that is supported by a specific image frame may reference that image in the INFERRED FROM / IMAGE row of the included TID 3010 “Log Entry Qualifiers” template.

Type:: Extensible
Order:: Significant

Table TID 3110. Impressions or Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	EV (121071, DCM, "Finding")	1	U	BCID 3728 “Cath Findings”
2	>	HAS PROPERTIES	CODE	EV (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
3	>	HAS PROPERTIES	CODE	EV (G-C0E3, SRT, "Finding Site")	1	U
4	>>	HAS CONCEPT MOD	CODE	EV (G-A1F8, SRT, "Topographical modifier")	1	U	DCID 3019 “Cardiovascular Anatomic Location Modifiers”
5	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
6			TEXT	BCID 3419 “Findings Titles”	1	U
7	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

Content Item Descriptions

Row 3

Finding Site has no Baseline Context ID specified. Typically terms would be drawn from coronary segments, other arterial segments, myocardial segments, etc.

TID 3111 Percutaneous Entry

The Percutaneous Entry Template allows recording of the opening or closing of invasive access ports.

Type:: Extensible
Order:: Significant

Table TID 3111. Percutaneous Entry

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	EV (121156, DCM, "Percutaneous Entry Action")	1	M	DCID 3403 “Percutaneous Entry”
2	>	HAS CONCEPT MOD	CODE	EV (G-C171, SRT, "Laterality")	1	U	DCID 244 “Laterality”
3	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3112 Specimen Obtained

The Specimen Obtained Template allows recording of obtaining a specimen, and the identifiers for that specimen. This is particularly designed for blood samples that will be analyzed for blood oxygen-related measurements. The analysis of the sample may be recorded in one or more log entries using TID 3109 “Measurements”, or in a separate Structured Report SOP Instance referenced by a log entry using TID 3103 “Referenced Object”.

Type:: Extensible
Order:: Significant

Table TID 3112. Specimen Obtained

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	EV (121123, DCM, "Patient Status or Event")	1	M		DCID 3515 “Specimen Collection”
2	>	HAS ACQ CONTEXT	CODE	EV (R-00254, SRT, "Specimen Type")	1	UC	IFF specimen is blood sample	DCID 3520 “Blood Source Type”
3	>	HAS ACQ CONTEXT	CODE	EV (G-C0E9, SRT, "Procedure site")	1	U		BCID 3630 “Cardiovascular Anatomic Locations”
4	>	HAS PROPERTIES	INCLUDE	DTID 1009 “Subject Context, Specimen”	1	U

TID 3113 Patient Support

The Patient Support Template allows recording of the use of various support technologies, including oxygen, ventilation, pacing, etc.

Type:: Extensible
Order:: Significant

Table TID 3113. Patient Support

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	DCID 3530 “Oxygen Administration Actions”	1	U		DCID 3531 “Oxygen Administration”
2	>	HAS PROPERTIES	NUM	EV (121160, DCM, "Oxygen Administration Rate")	1	MC	IFF Row 1 Concept is (121161, DCM, "Begin Oxygen Administration")	UNITS = DT (l/min, UCUM, "l/min")
3	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
4			CODE	DCID 3550 “Circulatory Support Actions”	1	U		DCID 3553 “Circulatory Support”
5	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
6			CODE	DCID 3551 “Ventilation Actions”	1	U		DCID 3554 “Ventilation”
7	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U
8			CODE	DCID 3552 “Pacing Actions”	1	U		DCID 3555 “Pacing”
9	>		INCLUDE	DTID 3010 “Log Entry Qualifiers”	1	U

TID 3114 Patient Assessment

The Patient Assessment Template allows recording of the assessment of the patient's cardiovascular, neurological, and/or respiratory condition. A particular use of this template is for "vital signs", which are a specific subset of mandatory patient assessment measurements.

Type:: Extensible
Order:: Significant

Table TID 3114. Patient Assessment

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	EV (121123, DCM, "Patient Status or Event")	1	M		DT (121165, DCM, "Patient Assessment Performed") DT (PA-00500, SRT, "Observation of Vital Signs")
2	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (F-008EC, SRT, "Systolic blood pressure") $Units = DCID 3500 “Pressure Units” $Method = BCID 3560 “Blood Pressure Methods”
3	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (F-008ED, SRT, "Diastolic blood pressure") $Units = DCID 3500 “Pressure Units”
4	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (8867-4, LN, "Heart rate") $Units = EV ({H.B.}/min, UCUM, "BPM")
5	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (8310-5, LN, "Body temperature") $Units = EV (Cel, UCUM, "C")
6	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = DCID 3526 “Blood Gas Saturation” $Units = EV (%, UCUM, "%")
7	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (F-043E7, SRT, "Respiration rate") $Units = EV (/min, UCUM, "breaths/min")
8	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1-n	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (122195, DCM, "Pulse Strength") $Method = BCID 3442 “Peripheral Pulse Methods” $TargetSite = BCID 3440 “Peripheral Pulse Locations” $Units = DT ({0:4}, UCUM, "range 0:4")
9	>	HAS PROPERTIES	INCLUDE	DTID 300 “Measurement”	1	MC	IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs")	$Measurement = EV (F-009EA, SRT, "Pain Score") $Units = DT ({1:10}, UCUM, "range 1:10")
10	>	HAS PROPERTIES	CODE	DT (8884-9, LN, "Cardiac Rhythm")	1	U		BCID 3415 “Cardiac Rhythms”
11	>	HAS PROPERTIES	CODE	DT (9304-7, LN, "Respiration Rhythm")	1	U		BCID 3416 “Respiration Rhythms”
12	>	HAS PROPERTIES	CODE	DT (F-043E6, SRT, "Respiration Assessment")	1	U		BCID 3448 “Airway Assessment”
13	>	HAS PROPERTIES	CODE	DT (F-046D8, SRT, "Skin condition")	1-n	U		BCID 3446 “Skin Condition”
14	>	HAS PROPERTIES	CODE	DT (F-04317, SRT, "Patient mental state assessment")	1	U		No BCID
15	>	HAS PROPERTIES	TEXT	BCID 3441 “Patient Assessments”	1-n	U

Content Item Descriptions

Row 8	Pulse Strength allows the assessment of the patient's pulse at multiple locations using the Topographical concept modifier. It may also be used for a single pulse strength measurement from an unspecified location, as is typical of vital signs assessments.
Row 16	Allows free text description of patient assessments that are not expressible by coded entries of Rows 10 to 14.

TID 3115 ECG ST Assessment

The ECG ST Assessment Template allows recording of the assessment of changes in the patient ECG relative to baseline.

Type:: Extensible
Order:: Significant

Table TID 3115. ECG ST Assessment

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	EV (121123, DCM, "Patient Status or Event")	1	M	DT (R-41D8B, SRT, "ECG Analysis")
2	>	HAS PROPERTIES	NUM	DT (122099, DCM, "ST change from baseline")	1-n	M	UNITS = EV (uV, UCUM, "uV")
3	>>	HAS CONCEPT MOD	CODE	DT (122148, DCM, "Lead ID")	1	M	BCID 3001 “ECG Leads”