I.8 OB-GYN Examples

The following are simple, non-comprehensive illustrations of report sections.

I.8.1 Example 1: OB-GYN Root with Observation Context

The following example shows the highest level of content items for a second or third trimester OB exam. Subsequent examples show details of section content,

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Subject Name

Jane Doe

TID 1007

1.3

Subject ID

123-45-6789

TID 1007

1.4

Procedure Study Instance UID

1.2.842.111724.7678.32.34

TID 1005

1.5

Procedure Study Component UID

1.2.842.111724.7678.55.34

TID 1005

1.6

Procedure Accession Number

20011007-21

TID 1005

1.7

Image Library

TID 5000

1.7.1

IMAGE 1

TID 5000

1.7.2

IMAGE 2

TID 5000

1.7.n

IMAGE N

TID 5000

1.8

Patient Characteristics

TID 5001

1.8.n

TID 5001

1.9

Summary

TID 5002

1.9.n

TID 5002

1.10

Fetal Biometry Ratios

TID 5004

1.10.n

TID 5004

1.11

Long Bones

TID 5006

1.11.n

TID 5006

1.12

Fetal Cranium

TID 5007

1.12.n

TID 5007

1.13

Biophysical Profile

TID 5009

1.13.n

TID 5009

1.14

Amniotic Sac

TID 5010

1.14.n

TID 5010

The following example shows the highest level of content items for a GYN exam. Subsequent examples show details of section content.

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.1

Subject Name

Jane Doe

TID 1007

1.2

Subject ID

123-45-6789

TID 1007

1.3

Image Library

TID 5000

1.3.1

IMAGE 1

TID 5000

1.3.2

IMAGE 2

TID 5000

1.3.n

IMAGE N

TID 5000

1.4

Patient Characteristics

TID 5001

1.4.n

TID 5001

1.5

Findings

TID 5012

1.5.1

Findings Site

Ovary

TID 5012

1.5.n

TID 5012

1.6

Findings

TID 5013

1.6.1

Findings Site

Ovarian Follicle

TID 5013

1.6.2

Laterality

Left

TID 5013

1.6.n

TID 5013

1.7

Findings

TID 5013

1.7.1

Findings Site

Ovarian Follicle

TID 5013

1.7.2

Laterality

Right

TID 5013

1.7.n

TID 5013

1.8

Pelvis and Uterus

TID 5015

1.8.n

TID 5015

I.8.2 Example 2: OB-GYN Patient Characteristics and Procedure Summary

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

….

TID 5000

1.8

Patient Characteristics

TID 5001

1.8.1

Gravida

5

TID 5001

1.8.2

Para

3

TID 5001

1.8.3

Aborta

2

TID 5001

1.8.4

Ectopic Pregnancies

1

TID 5001

1.9

Summary

TID 5002

1.9.1

LMP

20010101

TID 5002

1.9.2

EDD

20010914

TID 5002

1.9.3

EDD from LMP

20010914

TID 5002

1.9.4

EDD from average ultrasound age

20010907

TID 5002

1.9.5

Gestational age by ovulation date

185 d

TID 5002

1.9.6

Fetus Summary

TID 5003

1.9.6.1

EFW

2222 g

TID 300

1.9.6.1.1

+/-, range of measurement uncertainty

200 g

TID 310

1.9.6.1.2

Equation

EFW by AC, BPD, Hadlock 1984

TID 315

1.9.6.2

Comment

Enlarged cisterna magna

TID 5003

1.9.6.3

Comment

Choroid plexus cyst

TID 5003

I.8.3 Example 3: OB-GYN Multiple Fetus

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.5

Summary

TID 5002

1.5.1

EDD from LMP

20020325

TID 5002

1.5.2

Fetus Summary

TID 5003

1.5.2.1

Fetus ID

A

TID 1008

1.5.2.2

EFW

1.6 Kg

TID 300

1.5.2.2.1

Equation

EFW by AC, BPD, Hadlock 1984

TID 315

1.5.2.2.2

+/-, range of measurement uncertainty

160g

TID 310

1.5.2.3

Fetal Heart Rate

120 {H.B.}/min

TID 300

1.5.3

Fetus Summary

TID 5003

1.5.3.1

Fetus ID

B

TID 1008

1.5.3.2

Comment

Choroid plexus cyst

TID 5003

1.5.3.3

EFW

1.4 kg

TID 300

1.5.3.3.1

Equation

EFW by AC, BPD, Hadlock 1984

TID 315

1.5.3.3.2

+/-, range of measurement uncertainty

140 g

TID 310

1.5.3.4

Fetal Heart Rate

135 {H.B.}/min

TID 300

1.6

Biophysical Profile

TID 5009

1.6.1

Fetus ID

A

TID 1008

1.6.n

1.7

Biophysical Profile

TID 5009

1.7.1

Fetus ID

B

TID 1008

1.7.n

I.8.4 Example 4: Biophysical Profile

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.9

Biophysical Profile

TID 5009

1.9.1

Gross Body Movement

2 {0:2}

TID 5009

1.9.2

Fetal Breathing

2 {0:2}

TID 5009

1.9.3

Fetal Tone

2 {0:2}

TID 5009

1.9.4

Fetal Heart Reactivity

2 {0:2}

TID 5009

1.9.5

Amniotic Fluid Volume

2 {0:2}

TID 5009

1.9.6

Biophysical Profile Sum Score

10 {0:10}

TID 5009

I.8.5 Example 5: Biometry Ratios

Optionally, but not shown, the ratios may have by-reference, inferred-from relationships to the content items holding the numerator and denominator values.

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.9

Fetal Biometry Ratios

TID 5004

1.9.1

HC/AC

77%

TID 5004

1.9.2

FL/AC

22 %

TID 5004

1.9.2.1

Normal Range Lower Limit

20 %

TID 312

1.9.2.2

Normal Range Upper Limit

24 %

TID 312

1.9.2.3

Normal Range Authority

Hadlock, AJR 1983

TID 312

1.9.3

FL/BPD

79 %

TID 5004

1.9.3.1

Normal Range Lower Limit

71 %

TID 312

1.9.3.2

Normal Range Upper Limit

81 %

TID 312

1.9.3.3

Normal Range Authority

Hohler, Am J of Ob and Gyn 1981

TID 312

1.9.4

Cephalic Index

82 %

TID 5004

1.9.4.1

Normal Range Lower Limit

70 %

TID 312

1.9.4.2

Normal Range Upper Limit

86 %

TID 312

1.9.4.3

Normal Range Authority

Hadlock, AJR 1981

TID 312

I.8.6 Example 6: Biometry

This example shows measurements and estimated gestational age.

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.8

Fetal Biometry

TID 5005

1.8.1

Biometry Group

TID 5008

1.8.1.1

Biparietal Diameter

5.5 cm

TID 300

1.8.1.2

Biparietal Diameter

5.3 cm

TID 300

1.8.1.3

Biparietal Diameter

5.4 cm

TID 300

1.8.1.3.1

Derivation

Mean

TID 300

1.8.1.4

Gestational Age

190 d

TID 5008

1.8.1.4.1

Equation

Jeanty, 1982

TID 5008

1.8.1.4.2

5th Percentile Value of population

131 d

TID 5008

1.8.1.4.3

95th Percentile Value of population

173 d

TID 5008

1.8.2

Biometry Group

TID 5008

1.8.2.1

Occipital-Frontal Diameter

18.1 cm

TID 300

1.8.3

Biometry Group

TID 5008

1.8.3.1

Head Circumference

34.3 cm

TID 300

1.8.3.1.1

Derivation

Estimated

TID 300

1.8.4

Biometry Group

TID 5008

1.8.4.1

Abdominal Circumference

34.9 cm

TID 300

1.8.4.2

Abdominal Circumference

34.3 cm

TID 300

1.8.4.3

Abdominal Circumference

34.3 cm

TID 300

1.8.4.4

Abdominal Circumference

34.5 cm

TID 300

1.8.4.4.1

Derivation

Mean

TID 300

1.8.4.5

Gestational Age

190 d

TID 5008

1.8.4.5.1

Equation

Hadlock, 1984

TID 5008

1.8.4.5.2

2 Sigma Lower Value of population

184 d

TID 5008

1.8.4.5.3

2 Sigma Upper Value of population

196 d

TID 5008

1.8.5

Biometry Group

TID 5008

1.8.5.1

Femur Length

4.5 cm

TID 300

1.8.5.n

TID 300

This example shows measurements and with percentile ranking.

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.8

Fetal Biometry

TID 5005

1.8.1

Biometry Group

TID 5008

1.8.1.1

Biparietal Diameter

5.5 cm

TID 300

1.8.1.2

Biparietal Diameter

5.3 cm

TID 300

1.8.1.3

Biparietal Diameter

5.4 cm

TID 300

1.8.1.3.1

Derivation

Mean

TID 300

1.8.1.4

Growth Percentile Rank

63 %

TID 5008

1.8.1.4.1

Equation

BPD, Jeanty 1982

TID 5008

1.8.2

Biometry Group

TID 5008

1.8.2.n

TID 300

I.8.7 Example 7: Amniotic Sac

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.6

Findings

TID 5010

1.6.1

Finding Site

Amniotic Sac

TID 5010

1.6.2

Amniotic Fluid Index

11 cm

TID 300

1.6.3

First Quadrant Diameter

10 cm

TID 300

1.6.4

Second Quadrant Diameter

12 cm

TID 300

1.6.5

Third Quadrant Diameter

11 cm

TID 300

1.6.6

Fourth Quadrant Diameter

12 cm

TID 300

I.8.8 Example 8: OB-GYN Ovaries

The content structure in the example below conforms to TID 5012 “Ovaries Section”. The example shows the volume derived from three perpendicular diameters.

Ovaries Example

Figure I.8-1. Ovaries Example


Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.9

Findings

TID 5012

1.9.1

Finding Site

Ovary

TID 5012

1.9.2

Ovary

TID 5016

1.9.2.1

Left Ovary Volume

6 cm3

TID 300

1.9.2.2

Left Ovary Length

3 cm

TID 300

1.9.2.3

Left Ovary Length

3 cm

TID 300

1.9.2.4

Left Ovary Length

3 cm

TID 300

1.9.2.4.1

Derivation

Mean

TID 300

1.9.2.5

Left Ovary Width

2 cm

TID 300

1.9.2.5.1

Derivation

Mean

TID 300

1.9.2.6

Left Ovary Height

2 cm

TID 300

1.9.2.6.1

Derivation

Mean

TID 300

1.9.3

Ovary

TID 5016

1.9.3.1

Right Ovary Volume

7 cm3

TID 300

1.9.3.2

TID 300

I.8.9 Example 9: OB-GYN Follicles

The content structure in the example below conforms to TID 5013 “Follicles Section”. It uses multiple measurements and derived averages for each of the perpendicular diameters.

Follicles Example

Figure I.8-2. Follicles Example


Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

TID 5000

1.8

Findings

TID 5013

1.8.1

Finding Site

Ovarian Follicle

TID 5013

1.8.2

Laterality

Right

TID 5013

1.8.3

Number of follicles in right ovary

2

TID 5013

1.8.4

Measurement Group

TID 5014

1.8.4.1

Identifier

#1

TID 5014

1.8.4.2

Volume

3 cm3

TID 300

1.8.4.3

Follicle Diameter

15 mm

TID 300

1.8.4.4

Follicle Diameter

13 mm

TID 300

1.8.4.5

Follicle Diameter

14 mm

TID 300

1.8.4.5.1

Derivation

Mean

TID 300

1.8.5

Measurement Group

TID 5014

1.8.5.1

Identifier

#2

TID 5014

1.8.5.2

Volume

4 cm3

TID 300

1.8.5.3

Follicle Diameter

18 mm

TID 300

1.9

Findings

TID 5013

1.9.1

Finding Site

Ovarian Follicle

TID 5013

1.9.2

Laterality

Left

TID 5013

1.9.3

Number of follicles in left ovary

1

TID 5013

1.9.4

Follicle Measurement Group

TID 5014

1.9.4.1

Identifier

#1

TID 5014

1.9.4.2

Volume

3 cm3

TID 300

1.9.4.3

Follicle Diameter

15 mm

TID 300

I.8.10 Example 10: Pelvis and Uterus

Nest

Code Meaning of Concept Name

Code Meaning or Example Value

TID

1

OB-GYN Ultrasound Procedure Report

TID 5000

1.n

….

1.9

Pelvis and Uterus

TID 5015

1.9.1

Uterus

TID 5016

1.9.1.1

Uterus Volume

136 cm3

TID 300

1.9.1.2

Uterus Length

9.5 cm

TID 300

1.9.1.3

Uterus Width

5.9 cm

TID 300

1.9.1.4

Uterus Height

4.2 cm

TID 300

1.9.2

Endometrium Thickness

4 mm

TID 5015

1.9.3

Cervix Length

5.3 cm

TID 5015