Cath Lab Clinical Report Templates 

The templates that comprise the Cardiac Catheterization Report are interconnected as shown in Figure A-7.

Cardiac Catheterization Report Template Hierarchy

Figure A-7. Cardiac Catheterization Report Template Hierarchy


Note

Figure A-7 shows the relationship of templates; it does not show the structural hierarchy of Content Items in the IOD.

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

  1. 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.

  2. 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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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

Condition

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