Cath Lab Clinical Report Templates

Cath Lab Clinical Report Templates
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TID 3800 Cardiac Catheterization Report Root

The Cardiac Cath Report provides the overall clinical results of the catheterization procedure and interventions. In many cases, more detailed information is optionally available in other reports (Hemodynamic Measurements, Procedure Log, etc.). That information is collected and summarized here (and referenced when available).

When a Discharge Summary section (row 12) is included, this report template covers the full set of information required for submission to the ACC NCDR™ (version 2.0) registry.

Note

The information required for such a submission must sometimes be reformatted from a single concept in these templates to two data elements for the registry, or vice versa.
This Template is expected to be used with the Basic Text SR or Enhanced SR IOD.3. This Cardiac Cath Report template is a baseline template within these SOP Classes that may be replaced; it is therefore in no sense binding for exchange of this type of report. It is solely an example of a possible encoding of the Cardiac Cath Report.

Type:: Extensible
Order:: Significant
Root:: Yes

Table TID 3800. Cardiac Catheterization Report Root

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (18745-0, LN, "Cardiac Catheterization Report")	1	M	Root node
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DCID 3739 “Cath Procedure Type”
3	>	HAS CONCEPT MOD	INCLUDE	DTID 1204 “Language of Content Item and Descendants”	1	M
4	>		INCLUDE	DTID 3601 “Procedure Context”	1	M
5	>	CONTAINS	INCLUDE	DTID 3802 “Cardiovascular Patient History”	1	U
6	>	CONTAINS	INCLUDE	DTID 3803 “Patient Presentation, Cath”	1	M
7	>	CONTAINS	INCLUDE	DTID 3806 “Cath Procedure”	1	M
8	>	CONTAINS	INCLUDE	DTID 3810 “Cardiac Catheterization Findings”	1	M
9	>	CONTAINS	INCLUDE	DTID 3807 “Percutaneous Coronary Intervention Procedure”	1	U
10	>	CONTAINS	INCLUDE	DTID 3809 “Other Interventional Procedures”	1-n	U
11	>	CONTAINS	INCLUDE	DTID 3820 “Adverse Outcomes, Cath”	1	M
12	>	CONTAINS	INCLUDE	DTID 3824 “Summary, Cath”	1	M
13	>	CONTAINS	INCLUDE	DTID 3828 “Discharge Summary, Cath”	1	U

TID 3802 Cardiovascular Patient History

This template contains information about a cardiovascular patient's past medical history that is relevant for the interpretation of the SR document of which it is part. This information is considered to have some degree of "persistence" across different episodes of care.

Type:: Extensible
Order:: Significant

Table TID 3802. Cardiovascular Patient History

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121060, DCM, "History")	1	M
2	>	CONTAINS	TEXT	EV (121060, DCM, "History")	1	U
3	>	CONTAINS	CONTAINER	DT (11450-4, LN, "Problem List")	1	U
4	>>	CONTAINS	TEXT	DCID 3769 “Concern Types”	1-n	U
5	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1-n	U	$Problem = DCID 3756 “Cardiac Patient Risk Factors”
6	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (G-023F, SRT, "History of Diabetes mellitus") $Therapy = DCID 3722 “Diabetic Therapy”
7	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (G-0269, SRT, "History of Hypertension") $Therapy = DCID 3760 “Hypertension Therapy”
8	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (R-102B8, SRT, "History of Hypercholesterolemia") $Therapy = DCID 3761 “Antilipemic Agents”
9	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (D3-30000, SRT, "Arrhythmia") $Therapy = DCID 3762 “Antiarrhythmic Agents”
10	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (G-03AA, SRT, "History of Myocardial infarction") $ModType = DT (122170, DCM, "Type of Myocardial Infarction") $ModValue = DCID 3723 “MI Types” $Therapy = DCID 3764 “Myocardial Infarction Therapies”
11	>>	CONTAINS	INCLUDE	DTID 3829 “Problem Properties”	1	U	$Problem = EV (G-0069, SRT, "History of Kidney disease") $Stage = DCID 3778 “Stages”
12	>	CONTAINS	CONTAINER	DT (29762-2, LN, "Social History")	1	U
13	>>	CONTAINS	TEXT	EV (F-02455, SRT, "Social History")	1	U
14	>>	CONTAINS	TEXT	DCID 3774 “Social History”	1-n	U
15	>>	CONTAINS	CODE	EV (F-93109, SRT, "Tobacco Smoking Behavior")	1	U	DCID 3724 “Smoking History”
16	>>	CONTAINS	CODE	DT (F-931D4, SRT, "Drug misuse behavior")	1	U	DT (D9-30400, SRT, "Cocaine Abuse")
17	>	CONTAINS	CONTAINER	DT (10167-5, LN, "Past Surgical History")	1	U
18	>>	CONTAINS	TEXT	EV (121060, DCM, "History")	1-n	U
19	>>	CONTAINS	INCLUDE	DTID 3830 “Procedure Properties”	1-n	U	$ProcType = DT (P0-009C3, SRT, "Surgical Procedure") $Procedure = DCID 3721 “Cardiovascular Surgeries”
20	>	CONTAINS	CONTAINER	DT (30954-2, LN, "Relevant Diagnostic Tests and/or Laboratory Data")	1	U
21	>>	CONTAINS	TEXT	EV (121060, DCM, "History")	1-n	U
22	>>	CONTAINS	INCLUDE	DTID 3830 “Procedure Properties”	1-n	U	$ProcType = DT (P0-00002, SRT, "Diagnostic procedure") $Procedure = DCID 3757 “Cardiac Diagnostic Procedures”
23	>>	CONTAINS	NUM	DT (2086-7, LN, "Cholesterol.in HDL")	1	U	UNITS = EV (mg/dl, UCUM, "mg/dl")
24	>>	CONTAINS	NUM	DT (2089-1, LN, "Cholesterol.in LDL")	1	U	UNITS = EV (mg/dl, UCUM, "mg/dl")
25	>	CONTAINS	CONTAINER	DT (10160-0, LN, "History of Medication Use")	1	U
26	>>	CONTAINS	TEXT	DT (111516, DCM, "Medication Type")	1-n	U
27	>>>	HAS PROPERTIES	CODE	DT (33999-4, LN, "Status")	1	U	DCID 3773 “Use Status”
28	>>	CONTAINS	CODE	DT (111516, DCM, "Medication Type")	1-n	U
29	>>>	HAS PROPERTIES	NUM	DT (G-C0B7, SRT, "Dosage")	1	U
30	>>>	HAS PROPERTIES	CODE	DT (33999-4, LN, "Status")	1	U	DCID 3773 “Use Status”
31	>	CONTAINS	CONTAINER	DT (10157-6, LN, "History of Family Member Diseases")	1	U
32	>>	CONTAINS	TEXT	EV (121060, DCM, "History")	1-n	U
33	>>	CONTAINS	CODE	EV (G-03E5, SRT, "Family history of clinical finding")	1-n	U	DCID 3758 “Cardiovascular Family History”
34	>>>	HAS PROPERTIES	CODE	EV (G-C32E, SRT, "Subject relationship")	1	M	DCID 7451 “Family Member”
35	>	CONTAINS	CONTAINER	DT (46264-8, LN, "History of medical device use")	1	U
36	>>	CONTAINS	TEXT	EV (121060, DCM, "History")	1	U
37	>>	CONTAINS	INCLUDE	DTID 3831 “Medical Device Use”	1-n	U	$Device = DCID 3777 “Implanted Devices”

TID 3803 Patient Presentation, Cath

This template describes the aspects of the patient that are specific to this clinical presentation (admission).

Type:: Extensible
Order:: Significant

Table TID 3803. Patient Presentation, Cath

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CONTAINER	EV (121110, DCM, "Patient Presentation")	1	M
2	>	CONTAINS	TEXT	EV (122128, DCM, "Patient Transferred From")	1	U
3	>	CONTAINS	DATETIME	EV (15, NCDR [2.0b], "Admission Date/Time")	1	U
4	>	CONTAINS	CODE	EV (17, NCDR [2.0b], "Admission Status")	1	U		DCID 3729 “Admission Status”
5	>	CONTAINS	CODE	EV (18, NCDR [2.0b], "Insurance Payor Type")	1	U		DCID 3730 “Insurance Payor”
6	>	CONTAINS	CODE	EV (46, NCDR [2.0b], "Congestive Heart Failure Prior to Procedure")	1	U		DCID 230 “Yes-No”
7	>	CONTAINS	CODE	EV (47, NCDR [2.0b], "NYHA Classification")	1	UC	IFF Row 6 Value code meaning is <yes>	DCID 3736 “NYHA Classification”
8	>	CONTAINS	CODE	EV (48, NCDR [2.0b], "Noninvasive Testing - Ischemia")	1	U		DCID 3737 “Non-invasive Test - Ischemia”
9	>	CONTAINS	CODE	EV (49, NCDR [2.0b], "Pre-Cath Angina Type")	1	U		DCID 3738 “Pre-Cath Angina Type”
10	>	CONTAINS	CODE	EV (50, NCDR [2.0b], "Pre-Cath Canadian Classification")	1	U		DCID 3719 “Canadian Clinical Classification”
11	>	CONTAINS	CODE	EV (51, NCDR [2.0b], "Acute Coronary Syndrome Time Period")	1	UC	IFF Row 9 Value code meaning is <ACS>	DCID 3735 “Acute Coronary Syndrome Time Period”
12	>	CONTAINS	CONTAINER	EV (121109, DCM, "Indications for Procedure")	1	U
13	>>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	U		DCID 3727 “Indications for Catheterization”
14	>	CONTAINS	NUM	EV (10230-1, LN, "LV Ejection Fraction")	1-n	U		UNITS = EV (%, UCUM, "%")
15	>>	HAS CONCEPT MOD	CODE	EV (G-C036, SRT, "Measurement method")	1	U		DCID 3744 “EF Testing Method”
16	>>		INCLUDE	DTID 1000 “Quotation”	1	U
17	>	CONTAINS	CODE	EV (121069, DCM, "Previous Finding")	1-n	U		DCID 3700 “Cath Diagnosis”
18	>	CONTAINS	TEXT	EV (121110, DCM, "Patient Presentation")	1	U

TID 3806 Cath Procedure

This template describes the patient-related information about this specific clinical encounter (catheterization).

Type:: Extensible
Order:: Significant

Table TID 3806. Cath Procedure

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121064, DCM, "Current Procedure Descriptions")	1	M
2	>	CONTAINS	DATETIME	EV (52, NCDR [2.0b], "Procedure DateTime")	1	M
3	>	CONTAINS	TEXT	EV (53, NCDR [2.0b], "Procedure Number in this admission")	1	U	Up to three numeric characters
4	>	CONTAINS	TEXT	EV (121065, DCM, "Procedure Description")	1	U
5	>	CONTAINS	COMPOSITE	EV (121120, DCM, "Cath Lab Procedure Log")	1-n	U
6	>	CONTAINS	NUM	EV (55, NCDR [2.0b], "Fluoroscopy Time")	1	U	UNITS = DT (min, UCUM, "min")
7	>	CONTAINS	NUM	EV (122130, DCM, "Dose Area Product")	1	U	UNITS = DT (mGy.cm2, UCUM, "mGy.cm2")
8	>	CONTAINS	PNAME	EV (76, NCDR [2.0b], "Catheterization Operator")	1	M
9	>	CONTAINS	PNAME	EV (121088, DCM, "Fellow")	1-n	U
10	>	CONTAINS	PNAME	BCID 7453 “Performing Roles”	1-n	U
11	>	CONTAINS	CODE	EV (122129, DCM, "PCI during this procedure")	1	U	DCID 230 “Yes-No”
12	>	CONTAINS	CONTAINER	EV (F-04460, SRT, "Medication Given")	1	M
13	>>	CONTAINS	CODE	EV (57, NCDR [2.0b], "Thrombolytics")	1	U	DCID 3740 “Thrombolytic Administration”
14	>>	CONTAINS	CODE	EV (58, NCDR [2.0b], "IIb/IIIa Blockade")	1	U	DCID 3741 “Medication Administration, Lab Visit”
15	>>	CONTAINS	CODE	EV (59, NCDR [2.0b], "Heparin")	1-n	U	DCID 3742 “Medication Administration, PCI”
16	>>	CONTAINS	CODE	EV (60, NCDR [2.0b], "Aspirin")	1	U	DCID 3741 “Medication Administration, Lab Visit”
17	>>	CONTAINS	CODE	EV (61, NCDR [2.0b], "Clopidogrel/Ticlopidine")	1	U	DCID 3743 “Clopidogrel/ticlopidine Administration”
18	>>	CONTAINS	TEXT	EV (122083, DCM, "Drug administered")	1-n	U
19	>	CONTAINS	CODE	EV (122138, DCM, "Circulatory Support")	1-n	U	DCID 3553 “Circulatory Support”
20	>	CONTAINS	CODE	EV (74, NCDR [2.0b], "Percutaneous Entry Site")	1	M	DCID 3746 “Percutaneous Entry Site”
21	>	CONTAINS	CODE	EV (75, NCDR [2.0b], "Closure Device")	1	U	DCID 3747 “Percutaneous Closure”

Content Item Descriptions

Row 3

Procedure Number (this admission) is specified as a numeric text string, and shall be treated as the ordinal of this catheterization procedure within the admission (i.e., "1" for the first catheterization, "2" for the second, etc.).

TID 3807 Percutaneous Coronary Intervention Procedure

This template describes the various aspects of a coronary intervention.

Type:: Extensible
Order:: Significant

Table TID 3807. Percutaneous Coronary Intervention Procedure

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121064, DCM, "Current Procedure Descriptions")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DT (122061, DCM, "Percutaneous Coronary Intervention")
3	>	CONTAINS	PNAME	EV (121114, DCM, "Performing Physician")	1	M
4	>	CONTAINS	PNAME	EV (121088, DCM, "Fellow")	1-n	U
5	>	CONTAINS	PNAME	DCID 7452 “Organizational Roles”	1-n	U
6	>	CONTAINS	CODE	EV (G-C09C, SRT, "Procedure Priority")	1	M	DCID 3414 “Procedure Urgency”
7	>	CONTAINS	CONTAINER	EV (121109, DCM, "Indications for Procedure")	1	U
8	>>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	U	DCID 3726 “Indications for Coronary Intervention”
9	>>	CONTAINS	CODE	EV (122172, DCM, "Acute MI Present")	1	U	DCID 230 “Yes-No”
10	>>>	HAS PROPERTIES	CODE	DT (122170, DCM, "Type of Myocardial Infarction")	1	U	DCID 3723 “MI Types”
11	>>>	HAS PROPERTIES	DATETIME	EV (122173, DCM, "ST Elevation Onset DateTime")	1	U
12	>>	CONTAINS	TEXT	EV (121071, DCM, "Finding")	1-n	U
13	>	CONTAINS	NUM	EV (122175, DCM, "Number of lesion interventions attempted")	1	M	UNITS = EV (1, UCUM, "units")
14	>	CONTAINS	NUM	EV (122176, DCM, "Number of lesion interventions successful")	1	M	UNITS = EV (1, UCUM, "units")
15	>	CONTAINS	CODE	EV (122177, DCM, "Procedure Result")	1	M	DCID 3749 “PCI Procedure Result”
16	>	CONTAINS	TEXT	EV (122177, DCM, "Procedure Result")	1	U
17	>	CONTAINS	INCLUDE	DTID 3808 “Lesion Intervention Information”	1-n	M

Content Item Descriptions

Rows 8 and 12	Allow the recording of findings as either codes or as text; the same finding shall not be recorded as both.
Rows 15 and 16	Allow the recording of procedure results as either codes or as text, but not as both.

TID 3808 Lesion Intervention Information

Type:: Extensible
Order:: Significant

Table TID 3808. Lesion Intervention Information

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CONTAINER	EV (122178, DCM, "Lesion Intervention Information")	1	M
2	>	CONTAINS	INCLUDE	DTID 3105 “Lesion Identification and Properties”	1	M
3	>	CONTAINS	CODE	EV (108, NDR [2.0b], "Previous Dilation")	1	U		DCID 3750 “Previously Dilated Lesion”
4	>	CONTAINS	CODE	EV (103, NDR [2.0b], "Guidewire crossing lesion")	1	U		DCID 3752 “Guidewire Crossing”
5	>	CONTAINS	CODE	EV (G-C50A, SRT, "Uses Equipment")	1-n	M		DCID 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	TEXT	EV (121145, DCM, "Description of Material")	1	U
8	>>	HAS PROPERTIES	NUM	DCID 3423 “Numeric Device Characteristics”	1-n	U
9	>>	HAS PROPERTIES	NUM	DCID 3425 “Intervention Parameters”	1-n	U
10	>>	HAS PROPERTIES	DATETIME	EV (122105, DCM, "DateTime of Intervention")	1	U
11	>>	HAS PROPERTIES	NUM	EV (122106, DCM, "Duration of Intervention")	1	U		UNITS = EV (s, UCUM, "s")
12	>	CONTAINS	NUM	EV (R-101BB, SRT, "Lumen Diameter Stenosis")	1	M		UNITS = EV (%, UCUM, "%")
13	>>	HAS CONCEPT MOD	CODE	EV (G-72BB, SRT, "Catheterization Procedure Phase")	1	M		EV (G-7298, SRT, "Post-intervention Phase")
14	>>	HAS CONCEPT MOD	CODE	EV (121401, DCM, "Derivation")	1	U		DCID 3745 “Calculation Method”
15	>>		INCLUDE	DTID 1000 “Quotation”	1	U
16	>	CONTAINS	CODE	EV (122110, DCM, "Post- Intervention TIMI Flow")	1	U		DCID 3713 “TIMI Flow Characteristics”
17	>	CONTAINS	CODE	EV (115, NCDR [2.0b], "Dissection in segment observed")	1	U		DCID 230 “Yes-No”
18	>	CONTAINS	CODE	EV (116, NCDR [2.0b], "Acute closure observed")	1	U		DCID 230 “Yes-No”
19	>	CONTAINS	CODE	EV (117, NCDR [2.0b], "Acute closure re-opened")	1	UC	IFF Row 18 value is <yes>	DCID 230 “Yes-No”
20	>	CONTAINS	CODE	EV (118, NCDR [2.0b], "Perforation occurred")	1	U		DCID 230 “Yes-No”
21	>	CONTAINS	IMAGE	DT (121080, DCM, "Best illustration of finding")	1	U
22	>	CONTAINS	TEXT	DT (122177, DCM, "Procedure Result")	1	U

TID 3809 Other Interventional Procedures

Type:: Extensible
Order:: Significant

Table TID 3809. Other Interventional Procedures

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121064, DCM, "Current Procedure Descriptions")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	BCID 3406 “Non-coronary Transcatheter Interventions”
3	>	CONTAINS	TEXT	EV (121065, DCM, "Procedure Description")	1	U
4	>	CONTAINS	CODE	DT (121065, DCM, "Procedure Description")	1	U	No BCID
5	>	CONTAINS	TEXT	DT (122177, DCM, "Procedure Result")	1	U

Content Item Descriptions

Rows 3 and 4

Allow the recording of procedure description as either code or as text; the same description shall not be recorded as both.

TID 3810 Cardiac Catheterization Findings

The Cardiac Catheterization Findings Template provides the structure for the diagnostic findings of the cath procedure, organized into sub-sections based on type of sub-procedure. It also provides for top-level summary findings and diagnoses.

Type:: Extensible
Order:: Significant

Table TID 3810. Cardiac Catheterization Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	CONTAINS	INCLUDE	DTID 3812 “Hemodynamic Findings”	1	U
3	>	CONTAINS	INCLUDE	DTID 3817 “Coronary Arteriography Findings”	1	U
4	>	CONTAINS	INCLUDE	DTID 3814 “Left Ventriculography Findings”	1	U
5	>	CONTAINS	INCLUDE	DTID 3815 “Right Ventriculography Findings”	1	U
6	>	CONTAINS	INCLUDE	DTID 3818 “Other Cardiographic Findings”	1-n	U
7	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	U	DCID 3700 “Cath Diagnosis”
8	>>	HAS PROPERTIES	CODE	EV (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
9	>	CONTAINS	TEXT	EV (121071, DCM, "Finding")	1-n	U

Content Item Descriptions

Rows 7 and 9

Allow the recording of findings as either codes or as text; the same finding shall not be recorded as both.

TID 3812 Hemodynamic Findings

Type:: Extensible
Order:: Significant

Table TID 3812. Hemodynamic Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DT (PA-50030, SRT, "Hemodynamic measurements")
3	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	U	DCID 3640 “Hypertension”
4	>>		INCLUDE	DTID 1350 “Negation Modifier, Presence of Finding”	1	U
5	>>	HAS PROPERTIES	CODE	EV (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
6	>	CONTAINS	CODE	DCID 3641 “Hemodynamic Assessments”	1-n	U	DCID 3642 “Degree Findings”
7	>>	HAS PROPERTIES	CODE	EV (G-C0B2, SRT, "Condition")	1	U	EV (R-102B9, SRT, "Large v-wave")
8	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1	U	EV (R-102BA, SRT, "Diastolic pressure equalization")
9	>	CONTAINS	INCLUDE	DTID 3819 “Common Findings”	1-n	U	$Report = DT (122120, DCM, "Hemodynamics Report")

Content Item Descriptions

Row 4

(Through DTID 3819 Common Findings Template) may be used to encode any significant hemodynamic numeric measurements. For reference, see Templates 3550 Pressure Waveform Measurements, and 3560 Derived Hemodynamic Measurements.

TID 3814 Left Ventriculography Findings

The information contained here about the left ventricle is relatively qualitative in nature. It is a high-level summary of the more detailed information that may be contained in an optional Quantitative Ventricular Analysis report. This template addresses findings about any ventricular septal defect (Row 7), the myocardial wall (Row 11), and about the aortic root (Row 16).

Type:: Extensible
Order:: Significant

Table TID 3814. Left Ventriculography Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DT (P5-30041, SRT, "Left Ventriculography")
3	>	CONTAINS	CODE	EV (F-30117, SRT, "Left Ventricular Function - Finding")	1	M	DCID 242 “Normal-Abnormal”
4	>		INCLUDE	DTID 300 “Measurement”	1	M	$Measurement = EV (10230-1, LN, "LV Ejection Fraction") $Units = EV (%, UCUM, "%") $Method = DCID 3748 “Angiographic EF Testing Method” $Derivation = DCID 3745 “Calculation Method”
5	>	CONTAINS	CODE	EV (F-0224E, SRT, "Left Ventricular Cavity Size")	1	U	DCID 3705 “Chamber Size”
6	>	CONTAINS	CODE	EV (F-02225, SRT, "Left Ventricular Contractility")	1	U	DCID 3706 “Overall Contractility”
7	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1	U	EV (D4-31159, SRT, "Ventricular Septal Defect")
8	>>	HAS PROPERTIES	CODE	EV (G-C504, SRT, "Associated Morphology")	1	U	DCID 3707 “VSD Description”
9	>	CONTAINS	INCLUDE	DTID 3816 “Ventricular Assessment”	1	U
10	>	CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	U
11	>>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M	DT (T-D0772, SRT, "Myocardial Wall")
12	>>	CONTAINS	CODE	EV (18179-2, LN, "Wall Segment")	1-n	M	BCID 3717 “Myocardial Wall Segments”
13	>>>	HAS PROPERTIES	CODE	EV (F-32050, SRT, "Cardiac Wall Motion")	1	M	DCID 3703 “Wall Motion”
14	>>>	HAS PROPERTIES	CODE	EV (G-C504, SRT, "Associated Morphology")	1	U	DCID 3704 “Myocardium Wall Morphology Findings”
15	>>>	HAS PROPERTIES	NUM	DT (G-C1E3, SRT, "Score")	1	U
16	>	CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	U
17	>>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M	DT (F-04403, SRT, "Aortic Root")
18	>>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	M	DCID 3709 “Aortic Root Description”

TID 3815 Right Ventriculography Findings

The information contained here about right ventricle is relatively qualitative in nature. It is a high-level summary of the more detailed information that may be contained in an optional Quantitative Ventricular Analysis report.

Type:: Extensible
Order:: Significant

Table TID 3815. Right Ventriculography Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DT (P5-3003F, SRT, "Right Ventriculography")
3	>		INCLUDE	DTID 300 “Measurement”	1	M	$Measurement = EV (10231-9, LN, "RV Ejection Fraction")) $Units = EV (%, UCUM, "%") $Method = DCID 3748 “Angiographic EF Testing Method” $Derivation = DCID 3745 “Calculation Method”
4	>	CONTAINS	CODE	EV (F-022A1, SRT, "Right Ventricular Cavity Size")	1	U	DCID 3705 “Chamber Size”
5	>	CONTAINS	CODE	EV (F-0227A, SRT, "Right Ventricular Contractility")	1	U	DCID 3706 “Overall Contractility”
6	>	CONTAINS	INCLUDE	DTID 3816 “Ventricular Assessment”	1	U

TID 3816 Ventricular Assessment

Type:: Extensible
Order:: Significant

Table TID 3816. Ventricular Assessment

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1-n	U
2	>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M	DCID 3701 “Cardiac Valves and Tracts”
3	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	M	DCID 3711 “Valvular Abnormalities”
4	>>	HAS PROPERTIES	CODE	EV (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
5	>>	HAS PROPERTIES	NUM	DT (G-C1E3, SRT, "Score")	1	U
6		CONTAINS	INCLUDE	DTID 3819 “Common Findings”	1-n	U	$Report = DT (122292, DCM, "Quantitative Ventriculography Report")

TID 3817 Coronary Arteriography Findings

The information contained here about with regards to coronary artery lesions is relatively qualitative in nature. It is a high-level summary of the more detailed information that may be contained in an optional Quantitative Coronary Arteriography report. This template addresses findings about the individual arteries (Row 4), and about individual lesions (Row 9).

Type:: Extensible
Order:: Significant

Table TID 3817. Coronary Arteriography Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	DT (P5-30100, SRT, "Coronary Arteriography")
3	>	CONTAINS	CODE	EV (F-04404, SRT, "Coronary artery feature ")	1	U	DCID 3710 “Coronary Dominance”
4	>	CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1-n	U
5	>>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M	BCID 3015 “Coronary Arteries”
6	>>>	HAS CONCEPT MOD	CODE	EV (G-A1F8, SRT, "Topographical modifier")	1	U	BCID 3019 “Cardiovascular Anatomic Location Modifiers”
7	>>	CONTAINS	CODE	EV (122134, DCM, "Vessel Morphology")	1-n	U	DCID 3712 “Vessel Descriptors”
8	>>	CONTAINS	INCLUDE	DTID 3819 “Common Findings”	1-n	U
9	>	CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1-n	U
10	>>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	M	DT (R-002EF, SRT, "Coronary artery lesion (culprit)")
11	>>	CONTAINS	INCLUDE	DTID 3105 “Lesion Identification and Properties”	1	M
12	>>	CONTAINS	INCLUDE	DTID 3819 “Common Findings”	1-n	U	$Report = DT (122291, DCM, "Quantitative Arteriography Report")

TID 3818 Other Cardiographic Findings

Type:: Extensible
Order:: Significant

Table TID 3818. Other Cardiographic Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121070, DCM, "Findings")	1	M
2	>	HAS CONCEPT MOD	CODE	EV (121058, DCM, "Procedure reported")	1	M	BCID 3428 “Imaging Procedures”
3	>	HAS CONCEPT MOD	CODE	EV (G-C0E3, SRT, "Finding Site")	1	U	BCID 3630 “Cardiovascular Anatomic Locations”
4	>	CONTAINS	INCLUDE	DTID 3819 “Common Findings”	1-n	M

TID 3819 Common Findings

Table TID 3819. Parameters

Parameter Name	Parameter Usage
$Report	Title of composite object (evidence document) referenced

Type:: Extensible
Order:: Significant

Table TID 3819. Common Findings

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			TEXT	EV (121071, DCM, "Finding")	1	U
2			IMAGE	DT (121080, DCM, "Best illustration of finding")	1	U
3			NUM	No BCID	1	U
4	>		INCLUDE	DTID 1000 “Quotation”	1	U
5			COMPOSITE	DT (122073, DCM, "Current procedure evidence")	1	U
6	>	HAS PROPERTIES	CODE	EV (121144, DCM, "Document Title")	1	U	$Report

Content Item Descriptions

Row 3

May be used to encode any significant image- or waveform-based numeric measurements, with post-coordination of the Concept Name using child Content Items (with relationship HAS CONCEPT MOD), as permitted by Section 6.2.4. The source of the measurement may be noted using the Quotation Template in Row 4.

TID 3820 Adverse Outcomes, Cath

Type:: Extensible
Order:: Significant

Table TID 3820. Adverse Outcomes, Cath

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121113, DCM, "Complications")	1	M
2	>	CONTAINS	CODE	EV (DD-60002, SRT, "Complication of Procedure")	1-n	U	DCID 3755 “Cath Complications”
3	>>	HAS CONCEPT MOD	CODE	EV (G-D709, SRT, "Relative Time")	1	U	DCID 12102 “Temporal Periods Relating to Procedure or Therapy”
4	>	CONTAINS	CODE	EV (DD-60002, SRT, "Complication of Procedure")	1-n	U	DCID 3754 “Vascular Complications”
5	>>	HAS CONCEPT MOD	CODE	EV (G-D709, SRT, "Relative Time")	1	U	DCID 12102 “Temporal Periods Relating to Procedure or Therapy”
6	>	CONTAINS	TEXT	EV (DD-60002, SRT, "Complication of Procedure")	1-n	U
7	>	CONTAINS	CODE	EV (122179, DCM, "Peri-procedural MI occurred")	1	U	DCID 230 “Yes-No”
8	>>	INFERRED FROM	NUM	EV (122181, DCM, "CK-MB peak")	1	U	UNITS = EV ([iU], UCUM, "International unit")
9	>>>	HAS PROPERTIES	NUM	EV (R-0038B, SRT, "Normal Range Upper Limit")	1	M	UNITS = EV ([iU], UCUM, "International unit")
10	>>	INFERRED FROM	NUM	EV (122180, DCM, "CK-MB baseline")	1	M	UNITS = EV ([iU], UCUM, "International unit")
11	>	CONTAINS	IMAGE	DT (121080, DCM, "Best illustration of finding")	1-n	U

Content Item Descriptions

Rows 2, 3 and 4

Allow the recording of outcomes as either codes or as text; the same outcome shall not be recorded as both.

TID 3824 Summary, Cath

Type:: Extensible
Order:: Non-Significant

Table TID 3824. Summary, Cath

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121111, DCM, "Summary")	1	M
2	>	CONTAINS	CODE	EV (121071, DCM, "Finding")	1-n	U	DCID 3728 “Cath Findings”
3	>>	HAS PROPERTIES	CODE	EV (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
4	>	CONTAINS	TEXT	EV (121111, DCM, "Summary")	1	U
5	>	CONTAINS	TEXT	EV (121075, DCM, "Recommendation")	1-n	U

TID 3828 Discharge Summary, Cath

Type:: Extensible
Order:: Significant

Table TID 3828. Discharge Summary, Cath

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1		CONTAINS	CONTAINER	EV (121115, DCM, "Discharge Summary")	1	M
2	>	CONTAINS	DATETIME	EV (122163, DCM, "Discharge DateTime")	1	U
3	>	CONTAINS	CODE	EV (122164, DCM, "Coronary Artery Bypass During This Admission")	1	U	DCID 230 “Yes-No”
4	>>	HAS PROPERTIES	CODE	EV (G-C09C, SRT, "Procedure Priority")	1	U	BCID 3414 “Procedure Urgency”
5	>>	HAS PROPERTIES	DATETIME	EV (122146, DCM, "Procedure DateTime")	1	U
6	>	CONTAINS	CODE	EV (122166, DCM, "Death During This Admission")	1	U	DCID 230 “Yes-No”
7	>>	HAS PROPERTIES	DATETIME	EV (122165, DCM, "Date of Death")	1	U
8	>>	HAS PROPERTIES	CODE	EV (25, NCDR [2.0b], "Primary Cause of Death")	1	U	DCID 3733 “Primary Cause of Death”
9	>>	HAS PROPERTIES	CODE	EV (122167, DCM, "Death During Catheterization")	1	U	DCID 230 “Yes-No”
10	>	CONTAINS	TEXT	EV (121111, DCM, "Summary")	1	U

TID 3829 Problem Properties

Table TID 3829. Parameters

Parameter Name	Parameter Usage
$Problem	Coded Value or Context Group for problem
$ModType	Modifier Name for Concept Name of problem
$ModValue	Modifier Value for Concept Name of problem
$Therapy	Coded Value or Context Group for therapy received for problem
$Stage	Coded Value or Context Group for problem or disease stage

Type:: Extensible
Order:: Significant

Table TID 3829. Problem Properties

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CONTAINER	EV (121430, DCM, "Concern")	1	M
2	>	CONTAINS	DATETIME	DT (121431, DCM, "DateTime Concern Noted")	1	U
3	>	CONTAINS	DATETIME	DT (121432, DCM, "DateTime Concern Resolved")	1	U
4	>	CONTAINS	CODE	DCID 3769 “Concern Types”	1	M	$Problem
5	>>	HAS CONCEPT MOD	CODE	$ModType	1-n	U	$ModValue
6	>>	HAS PROPERTIES	DATETIME	DT (111526, DCM, "DateTime Started")	1	U
7	>>	HAS PROPERTIES	DATETIME	DT (121433, DCM, "DateTime Problem Resolved")	1	U
8	>>	HAS PROPERTIES	CODE	DT (33999-4, LN, "Status")	1	U	DCID 3770 “Problem Status”
9	>>	HAS PROPERTIES	CODE	DT (G-C197, SRT, "Severity")	1	U	DCID 3716 “Severity”
10	>>	HAS PROPERTIES	CODE	DT (G-C16B, SRT, "Stage")	1	U	$Stage
11	>	CONTAINS	CODE	DT (11323-3, LN, "Health status")	1	U	DCID 3772 “Health Status”
12	>	CONTAINS	CODE	EV (P0-0000E, SRT, "Therapy")	1-n	U	$Therapy
13	>>	HAS PROPERTIES	CODE	DT (33999-4, LN, "Status")	1	U	DCID 3773 “Use Status”
14	>	CONTAINS	TEXT	EV (121106, DCM, "Comment")	1	U

TID 3830 Procedure Properties

Table TID 3830. Parameters

Parameter Name	Parameter Usage
$ProcType	Coded Value for class of procedure
$Procedure	Coded Value or Context Group for procedure
$ModType	Modifier Name for Concept Name of procedure
$ModValue	Modifier Value for Concept Name of procedure

Type:: Extensible
Order:: Significant

Table TID 3830. Procedure Properties

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Condition	Value Set Constraint
1			CODE	$ProcType	1	M		$Procedure
2	>	HAS CONCEPT MOD	CODE	$ModType	1-n	U		$ModValue
3	>	HAS PROPERTIES	DATETIME	DT (111526, DCM, "DateTime Started")	1	U
4	>	HAS PROPERTIES	COMPOSITE	EV (R-42B89, SRT, "Clinical Report")	1-n	U
5	>>	HAS PROPERTIES	CODE	EV (121144, DCM, "Document Title")	1	U
6	>	HAS PROPERTIES	TEXT	EV (R-42B89, SRT, "Clinical Report")	1-n	U		Description of report with URL or other reference for report
7	>	HAS PROPERTIES	TEXT	DT (121434, DCM, "Service Delivery Location")	1	U
8	>	HAS PROPERTIES	PNAME	DT (121435, DCM, "Service Performer")	1	UC	IF Service Performer is a person
9	>	HAS PROPERTIES	TEXT	DT (121435, DCM, "Service Performer")	1	UC	IF Service Performer is an organization
10	>	HAS PROPERTIES	TEXT	EV (121106, DCM, "Comment")	1	U

TID 3831 Medical Device Use

Table TID 3831. Parameters

Parameter Name	Parameter Usage
$Device	Coded Value for type of device

Type:: Extensible
Order:: Significant

Table TID 3831. Medical Device Use

	NL	Rel with Parent	VT	Concept Name	VM	Req Type	Value Set Constraint
1			CODE	EV (121436, DCM, "Medical Device Used")	1	M	$Device
2	>	HAS PROPERTIES	DATETIME	DT (111526, DCM, "DateTime Started")	1	U
3	>	HAS PROPERTIES	DATETIME	DT (111527, DCM, "DateTime Ended")	1	U
4	>	HAS PROPERTIES	CODE	DT (33999-4, LN, "Status")	1	U	DCID 3773 “Use Status”
5	>	HAS PROPERTIES	TEXT	EV (121106, DCM, "Comment")	1	U

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