Relevant Patient Information Templates

Relevant Patient Information Templates
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TID 9000 Relevant Patient Information for Breast Imaging

This template collects a patient's relevant information as it relates to breast imaging. This template, together with its subordinate templates, describes the history of a patient's reproductive system, hormone medications, past procedures, risk factors, and indicated problems as they relate to breast health.

Type:: Extensible
Order:: Significant

Table TID 9000. Relevant Patient Information for Breast Imaging

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (111511, DCM, "Relevant Patient Information for Breast Imaging")	1	M
2	>	HAS CONCEPT MOD	INCLUDE	DTID 1204 “Language of Content Item and Descendants”	1	M
3	>	CONTAINS	INCLUDE	DTID 3114 “Patient Assessment”	1	U
4	>	CONTAINS	INCLUDE	DTID 9001 “Gynecological History”	1	U
5	>	CONTAINS	INCLUDE	DTID 9002 “Medication, Substance, Environmental Exposure”	1	U	$ContainerConcept = EV (10160-0, LN, "History Of Medication Use") $CodeConcept = EV (111516, DCM, "Medication Type") $CodeValue = DCID 6080 “Gynecological Hormones”
6	>	CONTAINS	INCLUDE	DTID 9003 “Previous Procedure”	1	U	$ProcedureList = DCID 6083 “Procedures for Breast” $ProcedureModifier = DCID 6058 “Procedure Modifiers for Breast” $NumConceptName = DCID 6095 “Numeric Properties of Procedures” $LateralityValue = DCID 6022 “Side” $ProcedureResult = DCID 6063 “Interventional Procedure Results” $ComplicationValue = DCID 6062 “Interventional Procedure Complications”
7	>	CONTAINS	INCLUDE	DTID 9004 “Indicated Problem”	1	U	$ProblemList = DCID 6055 “Breast Clinical Finding Or Indicated Problem” $LateralityValue = DCID 6022 “Side” $LocationValue = DCID 6018 “Clockface Location or Region”, DCID 6020 “Quadrant Location”
8	>	CONTAINS	INCLUDE	DTID 9005 “Risk Factor”	1	U	$RiskList = DCID 6081 “Breast Cancer Risk Factors” $FamilyList = DCID 7451 “Family Member”

TID 9001 Gynecological History

This general template collects the details of a patient's reproductive system history, such as number of births, and gynecological surgery history.

Type:: Extensible
Order:: Significant

Table TID 9001. Gynecological History

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (R-20767, SRT, "Gynecological History")	1	M
2	>	HAS OBS CONTEXT	CODE	EV (111534, DCM, "Role of person reporting")	1	U	DCID 7450 “Person Roles”
3	>	CONTAINS	DATE	EV (11955-2, LN, "Date of last menstrual period")	1	U
4	>	CONTAINS	NUM	EV (111518, DCM, "Age when first menstrual period occurred")	1	U	UNITS = EV (a, UCUM, "Year")
5	>	CONTAINS	NUM	EV (111519, DCM, "Age at First Full Term Pregnancy")	1	U	UNITS = EV (a, UCUM, "Year")
6	>	CONTAINS	NUM	EV (11977-6, LN, "Para")	1	U	UNITS = EV (1, UCUM, "no units")
7	>	CONTAINS	NUM	EV (11639-2, LN, "Term")	1	U	UNITS = EV (1, UCUM, "no units")
8	>	CONTAINS	NUM	EV (11637-6, LN, "Preterm")	1	U	UNITS = EV (1, UCUM, "no units")
9	>	CONTAINS	NUM	EV (11636-8, LN, "Live Births")	1	U	UNITS = EV (1, UCUM, "no units")
10	>	CONTAINS	NUM	EV (111593, DCM, "LBW or IUGR")	1	U	UNITS = EV (1, UCUM, "no units")
11	>	CONTAINS	NUM	EV (11996-6, LN, "Gravida")	1	U	UNITS = EV (1, UCUM, "no units")
12	>	CONTAINS	NUM	EV (11612-9, LN, "Aborta")	1	U	UNITS = EV (1, UCUM, "no units")
13	>	CONTAINS	NUM	EV (33065-4, LN, "Ectopic Pregnancies")	1	U	UNITS = EV (1, UCUM, "no units")
14	>	CONTAINS	NUM	EV (111520, DCM, "Age at Menopause")	1	U	UNITS = EV (a, UCUM, "Year")
15	>	CONTAINS	NUM	EV (111521, DCM, "Age when hysterectomy performed")	1	U	UNITS = EV (a, UCUM, "Year")
16	>>	HAS CONCEPT MOD	CODE	EV (R-404ED, SRT, "Extent")	1	U	EV (R-404F1, SRT, "Complete") EV (R-404FE, SRT, "Partial")
17	>	CONTAINS	NUM	EV (111522, DCM, "Age when left ovary removed")	1	U	UNITS = EV (a, UCUM, "Year")
18	>	CONTAINS	NUM	EV (111523, DCM, "Age when right ovary removed")	1	U	UNITS = EV (a, UCUM, "Year")
19	>	CONTAINS	CODE	EV (111543, DCM, "Breast feeding history")	1	U	DCID 230 “Yes-No”
20	>>	HAS PROPERTIES	NUM	EV (111544, DCM, "Average breast feeding period")	1	U	UNITS = EV (wk, UCUM, "Week")
21	>	CONTAINS	CODE	EV (111532, DCM, "Pregnancy Status")	1	U	DCID 6096 “Pregnancy Status”
22	>	CONTAINS	CODE	EV (111391, DCM, "Menstrual Cycle Phase")	1	U	DCID 6163 “Menstrual Cycle Phase”

TID 9002 Medication, Substance, Environmental Exposure

This general template provides detailed information on a patient's medication or substance use, or exposure to environmental factors, including type and duration of use or exposure.

Table TID 9002. Parameters

Parameter Name	Parameter Usage
$ContainerConcept	Coded term for the concept name of the CONTAINER, identifying it as medication, substance, or environmental exposure history.
$CodeConcept	Coded term for the concept name of the CODE, identifying it as medication, substance, or environmental exposure.
$CodeValue	Coded term or Context Group for value of the medication, substance, or environmental exposure.

Type:: Extensible
Order:: Significant

Table TID 9002. Medication, Substance, Environmental Exposure

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	$ContainerConcept	1	M
2	>	CONTAINS	CODE	$CodeConcept	1-n	M	$CodeValue
3	>>	HAS CONCEPT MOD	CODE	EV (G-C032, SRT, "Classification")	1	U
4	>>	HAS OBS CONTEXT	CODE	EV (111534, DCM, "Role of person reporting")	1	U	DCID 7450 “Person Roles”
5	>>	HAS PROPERTIES	NUM	EV (111524, DCM, "Age Started")	1	U	UNITS = EV (a, UCUM, "Year")
6	>>	HAS PROPERTIES	NUM	EV (111525, DCM, "Age Ended")	1	U	UNITS = EV (a, UCUM, "Year")
7	>>	HAS PROPERTIES	DATETIME	EV (111526, DCM, "DateTime Started")	1	U
8	>>	HAS PROPERTIES	DATETIME	EV (111527, DCM, "DateTime Ended")	1	U
9	>>	HAS PROPERTIES	NUM	EV (G-7290, SRT, "Duration")	1	U	UNITS = DCID 6046 “Units of Follow-up Interval”
10	>>	HAS PROPERTIES	CODE	EV (111528, DCM, "Ongoing")	1	U	DCID 230 “Yes-No”
11	>>	HAS PROPERTIES	TEXT	EV (111529, DCM, "Brand Name")	1	U
12	>>	HAS PROPERTIES	NUM	DCID 6092 “Quantitative Concepts for Usage, Exposure”	1	U	The unit of measure shall be quantity per unit of time
13	>>	HAS PROPERTIES	CODE	DCID 6093 “Qualitative Concepts for Usage, Exposure Amount”	1	U	DCID 6090 “Relative Usage, Exposure Amount”
14	>>	HAS PROPERTIES	CODE	DCID 6094 “Qualitative Concepts for Usage, Exposure Frequency”	1	U	DCID 6091 “Relative Frequency of Event Values”

Content Item Descriptions

Row 3 "Classification"	No context group is provided for the value set, but it is recommended that values from a standard external coding scheme, such as SRT or NDC, be used.
Rows 13 & 14	If both of these content items are instantiated, the concept names selected for each should match. For example, use "Relative dose amount" as the concept name for row 13 with "Relative dose frequency" as the concept name for row 14.

TID 9003 Previous Procedure

This general template provides detailed information on a patient's previous procedure, surgery, or treatment.

Table TID 9003. Parameters

Parameter Name	Parameter Usage
$ProcedureList	Coded term or Context Group for value of Previous Procedure
$ProcedureModifier	Coded term or Context Group for value of Previous Procedure Modifier
$NumConceptName	Coded term or Context Group for the concept name of a numeric property of the Previous Procedure
$LateralityValue	Coded term or Context Group for value of Laterality
$ProcedureResult	Coded term or Context Group for value of Result of Procedure
$ComplicationValue	Coded term or Context Group for value of Complication

Type:: Extensible
Order:: Significant

Table TID 9003. Previous Procedure

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CONTAINER	EV (111513, DCM, "Relevant Previous Procedures")	1	M
2	>	CONTAINS	CODE	EV (111531, DCM, "Previous Procedure")	1-n	M		$ProcedureList
3	>>	HAS CONCEPT MOD	CODE	EV (111464, DCM, "Procedure Modifier")	1-n	U		$ProcedureModifier
4	>>	HAS OBS CONTEXT	CODE	EV (111534, DCM, "Role of person reporting")	1	U		DCID 7450 “Person Roles”
5	>>	HAS PROPERTIES	NUM	$NumConceptName	1-n	U
6	>>	HAS PROPERTIES	CODE	EV (G-C171, SRT, "Laterality")	1	U		$LateralityValue
7	>>	HAS PROPERTIES	DATETIME	EV (122146, DCM, "Procedure DateTime")	1	UC	XOR row 8
8	>>	HAS PROPERTIES	CODE	EV (111395, DCM, "Estimated Timeframe")	1	UC	XOR row 7	BCID 6164 “Time Intervals”
9	>>	HAS PROPERTIES	NUM	EV (R-42009, SRT, "Number of occurrences")	1	U		UNITS = EV (1, UCUM, "no units")
10	>>	HAS PROPERTIES	CODE	EV (DD-60002, SRT, "Complication of procedure")	1-n	U		$ComplicationValue
11	>>>	HAS PROPERTIES	CODE	EV (111466, DCM, "Severity of Complication")	1	U		DCID 251 “Severity of Complication”
12	>>	HAS PROPERTIES	CODE	EV (122177, DCM, "Procedure Result")	1	U		$ProcedureResult
13	>>	HAS PROPERTIES	INCLUDE	DTID 4207 “Breast Imaging Pathology Results”	1-n	U

TID 9004 Indicated Problem

This general template provides information about indicated problems presented by a patient. For example, indicated breast problems relating to the purpose for a mammographic examination.

Table TID 9004. Parameters

Parameter Name	Parameter Usage
$ProblemList	Coded term or Context Group for value of Indicated Problem
$LateralityValue	Coded term or Context Group for value of Laterality
$LocationValue	Coded term or Context Group for value of Location

Type:: Extensible
Order:: Significant

Table TID 9004. Indicated Problem

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (11450-4, LN, "Problem List")	1	M
2	>	CONTAINS	CODE	EV (111533, DCM, "Indicated Problem")	1-n	M	$ProblemList
3	>>	HAS OBS CONTEXT	CODE	EV (111534, DCM, "Role of person reporting")	1	U	DCID 7450 “Person Roles”
4	>>	HAS OBS CONTEXT	DATETIME	EV (111535, DCM, "DateTime problem observed")	1	U
5	>>	HAS PROPERTIES	CODE	EV (G-C171, SRT, "Laterality")	1	U	$LateralityValue
6	>>	HAS PROPERTIES	CODE	EV (G-C0E3, SRT, "Finding site")	1	U	$LocationValue
7	>>	HAS PROPERTIES	NUM	EV (G-7290, SRT, "Duration")	1	U
8	>>	HAS PROPERTIES	CODE	EV (R-407E7, SRT, "Frequency")	1	U	DCID 6091 “Relative Frequency of Event Values”
9	>>	HAS PROPERTIES	DATETIME	EV (111536, DCM, "DateTime of last evaluation")	1	U
10	>>	HAS PROPERTIES	TEXT	EV (121106, DCM, "Comment")	1	U

TID 9005 Risk Factor

This general template provides detailed information on the risk factors for a patient, related to medical history for themselves and family members.

Table TID 9005. Parameters

Parameter Name	Parameter Usage
$RiskList	Coded term or Context Group for value of Risk Factor
$FamilyList	Coded term or Context Group for value of Family Member with Risk Factor

Type:: Extensible
Order:: Significant

Table TID 9005. Risk Factor

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CONTAINER	EV (111515, DCM, "Relevant Risk Factors")	1	M
2	>	CONTAINS	CODE	EV (F-01500, SRT, "Risk factor")	1-n	M		$RiskList
3	>>	HAS CONCEPT MOD	CODE	EV (111530, DCM, "Risk Factor modifier")	1	U		EV (G-0002, SRT, "Family history of")
4	>>	HAS PROPERTIES	NUM	EV (18185-9, LN, "Gestational Age")	1	UC	IFF value of row 2 is (G-0305, SRT, "History of - premature delivery")
5	>>	HAS OBS CONTEXT	CODE	EV (111534, DCM, "Role of person reporting")	1	U		DCID 7450 “Person Roles”
6	>>	HAS PROPERTIES	NUM	EV (111538, DCM, "Age at Occurrence")	1	U		UNITS = EV (a, UCUM, "Year")
7	>>	HAS PROPERTIES	NUM	EV (G-7290, SRT, "Duration")	1	U		UNITS = DCID 6046 “Units of Follow-up Interval”
8	>>	HAS PROPERTIES	TEXT	EV (121106, DCM, "Comment")	1	U
9	>>	INFERRED FROM	CODE	EV (111537, DCM, "Family Member with Risk Factor")	1-n	U		$FamilyList
10	>>>	HAS PROPERTIES	NUM	EV (111538, DCM, "Age at Occurrence")	1	U		UNITS = EV (a, UCUM, "Year")
11	>>>	HAS CONCEPT MOD	CODE	EV (111539, DCM, "Menopausal phase")	1	U		DCID 6086 “Menopausal Phase”
12	>>>	HAS CONCEPT MOD	CODE	EV (111540, DCM, "Side of Family")	1	U		DCID 6097 “Side of Family”

TID 9006 Obstetric History

This general template collects the details of a patient's obstetric history for a current pregnancy. Information regarding previous pregnancies is conveyed using the Gynecological History Template.

Type:: Extensible
Order:: Significant

Table TID 9006. Obstetric History

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (R-20658, SRT, "Obstetric History")	1	M
2	>	CONTAINS	DATE	DCID 12003 “OB-GYN Dates”	1-n	U
3	>	CONTAINS	NUM	EV (18185-9, LN, "Gestational Age")	1	U	UNITS = EV (d, UCUM, "day")
4	>	CONTAINS	TEXT	EV (121106, DCM, "Comment")	1-n	U

Content Item Descriptions

Row 3 "Gestational Age"

Observation DateTime (0040,A032) for Content Item shall be present, in order to convey the date and time at which this Gestational Age was established.

TID 9007 General Relevant Patient Information

This template collects a patient's relevant information for general purpose use. This template, together with its subordinate templates, describes the history of a patient's reproductive system, medications, substance use, environmental exposure, past procedures, risk factors, and indicated problems.

Type:: Extensible
Order:: Significant

Table TID 9007. General Relevant Patient Information

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (111517, DCM, "Relevant Patient Information")	1	M
2	>	HAS CONCEPT MOD	INCLUDE	DTID 1204 “Language of Content Item and Descendants”	1	M
3	>	CONTAINS	INCLUDE	DTID 3114 “Patient Assessment”	1	U
4	>	CONTAINS	INCLUDE	DTID 9002 “Medication, Substance, Environmental Exposure”	1	U	$ContainerConcept = EV (10160-0, LN, "History Of Medication Use") $CodeConcept = EV (111516, DCM, "Medication Type")
5	>	CONTAINS	INCLUDE	DTID 9002 “Medication, Substance, Environmental Exposure”	1	U	$ContainerConcept = EV (111545, DCM, "Substance Use History") $CodeConcept = EV (111546, DCM, "Used Substance Type") $CodeValue = BCID 6089 “Substances”
6	>	CONTAINS	INCLUDE	DTID 9002 “Medication, Substance, Environmental Exposure”	1	U	$ContainerConcept = EV (111547, DCM, "Environmental Exposure History") $CodeConcept = EV (111548, DCM, "Environmental Factor")
7	>	CONTAINS	INCLUDE	DTID 9003 “Previous Procedure”	1	U	$LateralityValue = BCID 244 "Laterality"
8	>	CONTAINS	INCLUDE	DTID 9004 “Indicated Problem”	1	U	$LateralityValue = BCID 244 "Laterality"
9	>	CONTAINS	INCLUDE	DTID 9005 “Risk Factor”	1	U	$RiskList = BCID 6087 “General Risk Factors” $FamilyList = DCID 7451 “Family Member”
10	>	CONTAINS	INCLUDE	DTID 9001 “Gynecological History”	1	U
11	>	CONTAINS	INCLUDE	DTID 9006 “Obstetric History”	1	U
12	>	CONTAINS	INCLUDE	DTID 3802 “Cardiovascular Patient History”	1	U
13	>	CONTAINS	INCLUDE	DTID 351 “Previous Reports”	1	U

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