Echocardiography Procedure Report Templates 

TID 5200 Echocardiography Procedure Report

This template forms the top of a content tree that allows an ultrasound device to describe the results of an adult echocardiography imaging procedure. It is instantiated at the root node. It can also be included in other templates that need to incorporate echocardiography findings into another report as quoted evidence.

Type:

Extensible

Order:

Significant

Root:

Yes

Table TID 5200. Echocardiography Procedure Report

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (125200, DCM, "Adult Echocardiography Procedure Report")

1

M

Root node

2

>

HAS CONCEPT MOD

INCLUDE

DTID 1204 “Language of Content Item and Descendants”

1

U

3

>

HAS OBS CONTEXT

INCLUDE

DTID 1001 “Observation Context”

1

M

4

>

CONTAINS

CONTAINER

DT (55111-9, LN, "Current Procedure Descriptions")

1

U

5

>>

CONTAINS

CODE

DT (125203, DCM, "Acquisition Protocol")

1-n

M

BCID 12001 “Ultrasound Protocol Types”

6

>

CONTAINS

INCLUDE

DTID 5201 “Echocardiography Patient Characteristics”

1

U

7

>

CONTAINS

CONTAINER

EV (111028, DCM, "Image Library")

1

U

8

>>

CONTAINS

IMAGE

No purpose of reference

1-n

M

9

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-32600, SRT, "Left Ventricle")

$MeasType = DCID 12200 “Echocardiography Left Ventricle”

10

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-32500, SRT, "Right Ventricle")

$MeasType = DCID 12204 “Echocardiography Right Ventricle”

11

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-32300, SRT, "Left Atrium")

$MeasType = DCID 12205 “Echocardiography Left Atrium”

12

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-32200, SRT, "Right Atrium")

$MeasType = DCID 12206 “Echocardiography Right Atrium”

13

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-35400, SRT, "Aortic Valve")

$MeasType = DCID 12211 “Echocardiography Aortic Valve”

14

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-35300, SRT, "Mitral Valve")

$MeasType = DCID 12207 “Echocardiography Mitral Valve”

15

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-35200, SRT, "Pulmonic Valve")

$MeasType = DCID 12209 “Echocardiography Pulmonic Valve”

16

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-35100, SRT, "Tricuspid Valve")

$MeasType = DCID 12208 “Echocardiography Tricuspid Valve”

17

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-42000, SRT, "Aorta")

$MeasType = DCID 12212 “Echocardiography Aorta”

18

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-44000, SRT, "Pulmonary artery")

$MeasType = DCID 12210 “Echocardiography Pulmonary Artery”

19

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-48600, SRT, "Vena Cava")

$MeasType = DCID 12215 “Echocardiography Vena Cavae”

20

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-48581, SRT, "Pulmonary Venous Structure")

$MeasType = DCID 12214 “Echocardiography Pulmonary Veins”

21

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (T-39050, SRT, "Pericardial cavity")

$MeasType = DCID 12250 “Cardiac Ultrasound Common Linear Measurements”

22

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (P5-30031, SRT, "Cardiac Shunt Study")

$MeasType = DCID 12217 “Echocardiography Cardiac Shunt”

23

>

CONTAINS

INCLUDE

DTID 5202 “Echo Section”

1

U

$SectionSubject = EV (D4-30000, SRT, "Congenital Anomaly of Cardiovascular System")

$MeasType = DCID 12218 “Echocardiography Congenital”

24

>

CONTAINS

INCLUDE

DTID 5204 “Wall Motion Analysis”

1-n

U

$Procedure = DT (P5-B3121, SRT, "Echocardiography for Determining Ventricular Contraction")


Content Item Descriptions

Row 24

The wall motion findings of stress stage. There may be multiple Template instances to report wall motion findings of multiple stages.

TID 5201 Echocardiography Patient Characteristics

Patient Characteristic concepts in this template, which may replicate attributes in the Patient Study Module, are included here as possible targets of by-reference relationships from other content items in the SR tree.

Note

Several of the concepts in this template duplicate concepts in TID 1007 “Subject Context, Patient”. The difference in use is that this template has those concepts as primary observations of the patient, while in TID 1007 “Subject Context, Patient” the concepts are used to set (or reset) the context for other observations.

Type:

Extensible

Order:

Significant

Table TID 5201. Echocardiography Patient Characteristics

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121118, DCM, "Patient Characteristics")

1

M

2

>

CONTAINS

NUM

EV (121033, DCM, "Subject Age")

1

U

UNITS = DCID 7456 “Units of Measure for Age”

3

>

CONTAINS

CODE

EV (121032, DCM, "Subject Sex")

1

U

DCID 7455 “Sex”

4

>

CONTAINS

NUM

EV (8867-4, LN, "Heart Rate")

1

U

5

>

CONTAINS

NUM

EV (F-008EC, SRT, "Systolic Blood Pressure")

1

U

6

>

CONTAINS

NUM

EV (F-008ED, SRT, "Diastolic Blood Pressure")

1

U

7

>

CONTAINS

NUM

EV (8277-6, LN, "Body Surface Area")

1

M

8

>>

INFERRED FROM

CODE

EV (8278-4, LN, "Body Surface Area Formula")

1

U

BCID 3663 “Body Surface Area Equations”


TID 5202 Echo Section

This is a generic section heading Template for any of the anatomical headings. Measurements within a section heading appear as groups (by image mode, acquisition protocol, and/or protocol stage).

Table TID 5202. Parameters

Parameter Name

Parameter Usage

$SectionSubject

The subject modifier of the section heading container

$MeasType

The concept name of the measurement


Type:

Extensible

Order:

Significant

Table TID 5202. Echo Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

EV (G-C0E3, SRT, "Finding Site")

1

M

$SectionSubject

3

>

CONTAINS

CONTAINER

DT (125007, DCM, "Measurement Group")

1-n

M

4

>>

HAS CONCEPT MOD

CODE

EV (G-0373, SRT, "Image Mode")

1

U

BCID 12224 “Ultrasound Image Modes”

5

>>

HAS CONCEPT MOD

CODE

DT (125203, DCM, "Acquisition Protocol")

1

U

6

>>

HAS CONCEPT MOD

TEXT

DT (125203, DCM, "Acquisition Protocol")

1

U

7

>>

HAS ACQ CONTEXT

CODE

EV (18139-6, LN, "Stage")

1

U

BCID 12002 “Ultrasound Protocol Stage Types”

8

>>

CONTAINS

INCLUDE

DTID 5203 “Echo Measurement”

1-n

M

$Measurement = $MeasType

$Method = CID 12227 “Echocardiography Measurement Method”


Content Item Descriptions

Rows 4, 5

Type of measurement group. May be grouped by image mode, or acquisition protocol, or some other user or manufacturer designated classification

Row 7

For measurements acquired in a staged protocol, all measurements in a measurement group are acquired at the identified stage.

TID 5203 Echo Measurement

Table TID 5203. Parameters

Parameter Name

Parameter Usage

$Measurement

Coded term or Context Group for Concept Name of measurement

$Method

Value for Measurement Method


Type:

Extensible

Order:

Significant

Table TID 5203. Echo Measurement

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

INCLUDE

DTID 300 “Measurement”

1

M

$Measurement = $Measurement

$Method = $Method

$TargetSite = BCID 12236 “Echo Anatomic Sites”

$TargetSiteMod = BCID 12237 “Echocardiography Anatomic Site Modifiers”

2

>

HAS CONCEPT MOD

CODE

EV (G-C048, SRT, "Flow Direction")

1

U

BCID 12221 “Flow Direction”

3

>

HAS CONCEPT MOD

CODE

EV (R-40899, SRT, "Respiratory Cycle Point")

1

U

DCID 12234 “Respiration State”

4

>

HAS CONCEPT MOD

CODE

EV (R-4089A, SRT, "Cardiac Cycle Point")

1

U

DCID 12233 “Cardiac Phase”

5

>

HAS ACQ CONTEXT

CODE

EV (G-0373, SRT, "Image Mode")

1

U

DCID 12224 “Ultrasound Image Modes”

6

>

HAS ACQ CONTEXT

CODE

EV (111031, DCM, "Image View")

1

U

BCID 12226 “Echocardiography Image View”

7

>

HAS ACQ CONTEXT

CODE

EV (18139-6, LN, "Stage")

1

U

BCID 12002 “Ultrasound Protocol Stage Types”


Content Item Descriptions

Row 1

TID 300 specifies an "Equivalent Meaning of Concept Name" that allows the creating application to specify the preferred composed concept name representing the measurement and the associated post-coordination Concept Modifiers (e.g., the ASE terminology described in Section N.3 “Illustrative Mapping to ASE Concepts” in PS3.17 ).

TID 5204 Wall Motion Analysis

The Wall Motion Analysis Template is used to document wall motion scoring for any imaging modality.

Table TID 5204. Parameters

Parameter Name

Parameter Usage

$Procedure

The imaging procedure used for wall motion analysis.


Type:

Extensible

Order:

Significant

Table TID 5204. Wall Motion Analysis

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

EV (121058, DCM, "Procedure reported")

1

M

$Procedure

3

>

HAS ACQ CONTEXT

CODE

EV (18139-6, LN, "Stage")

1

U

BCID 3207 “Stress Test Procedure Phases”

4

>

CONTAINS

IMAGE

EV (125201, DCM, "Illustration of Finding")

1

U

5

>

CONTAINS

TEXT

EV (18118-0, LN, "LV Wall Motion Segmental Findings")

1

U

6

>

CONTAINS

NUM

DT (125202, DCM, "LV Wall Motion Score Index")

1

U

7

>>

HAS CONCEPT MOD

CODE

EV (G-E048, SRT, "Assessment Scale")

1

M

BCID 12238 “Wall Motion Scoring Schemes”

8

>

CONTAINS

CONTAINER

EV (121070, DCM, "Findings")

1

U

9

>>

HAS CONCEPT MOD

CODE

EV (G-C0E3, SRT, "Finding Site")

1

M

DT (T-D0772, SRT, "Myocardial Wall")

10

>>

CONTAINS

CODE

EV (18179-2, LN, "Wall Segment")

1-n

M

BCID 3717 “Myocardial Wall Segments”

11

>>>

HAS PROPERTIES

CODE

EV (F-32050, SRT, "Cardiac Wall Motion")

1

MC

IF row 12 is absent

DCID 3703 “Wall Motion”

12

>>>

HAS PROPERTIES

CODE

EV (G-C504, SRT, "Associated Morphology")

1

MC

IF row 11 is absent

DCID 3704 “Myocardium Wall Morphology Findings”

13

>>>

HAS PROPERTIES

NUM

DT (G-C1E3, SRT, "Score")

1

U

14

>>>

HAS PROPERTIES

NUM

EV (122624, DCM, "Wall Thickness Ratio end-systolic to end-diastolic")

1

U

UNITS = DT (%, UCUM, "%")


Content Item Descriptions

Row 3

The stage of the protocol at which these findings were scored. This row may be absent if this is a generic, non-staged scoring.

Row 4

Image that graphically depicts the segments and their scores.

Row 5

Text narration accompanying this stage.

Row 6

The composite score computed from the average of the scored segments

Row 7

The type of scoring scheme used to score this exam.

Row 8

A container of all of the individual segment findings for this stage. The container shall be present if the observer makes an assessment, including the assessment of Not Visualized. It shall not be present if no evaluation was made.

Rows 11, 12

Scar/thinning (in Row 12) may accompany akinesis and dyskinesis (in Row 11).

Row 13

A numeric designation for the score. Score ranges vary, typically 0-4 or 0-5. Numeric scores may depend on wall motion findings as well as morphology findings. See Table 5204-1 for conventional numeric assignment schemes. The UCUM annotation code enables specifying the numeric range, ({L:N}, UCUM, "scale L:N"), where L and N are the lower and upper ends of the range.

A description of the scoring schemes described in Table 5204-1 is available in Recommendations for Quantitation of the Left Ventricle by Two-Dimensional Echocardiography, Journal of the American Society of Echocardiography, Vol 2, No 5 358-367, Oct 1989.

Table 5204-1. Numeric Score Assignment for Segmental Findings

Conventional Numeric Assignment

Wall Motion Finding or Morphology Finding

4 Point

5 Point

5 Point with Graded Hypokinesis

-1

(F-32050, SRT, "Cardiac Wall Motion") = (R-0030D SRT, "Hyperkinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (R-0030D, SRT, "Hyperkinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (R-0030D, SRT, "Hyperkinesis")

0

(F-32050, SRT, "Cardiac Wall Motion") = (122288, DCM, "Not Visualized")

(F-32050, SRT, "Cardiac Wall Motion") = (122288, DCM, "Not Visualized")

(F-32050, SRT, "Cardiac Wall Motion") = (122288, DCM, "Not Visualized")

1

(F-32050, SRT, "Cardiac Wall Motion") = (R-00344, SRT, "Normal Wall Motion")

(F-32050, SRT, "Cardiac Wall Motion") = (R-00344, SRT, "Normal Wall Motion")

(F-32050, SRT, "Cardiac Wall Motion") = (R-00344, SRT, "Normal Wall Motion")

1.5

(F-32050, SRT, "Cardiac Wall Motion") = (R-00327, SRT, "Mild Hypokinesis")

2

(F-32050, SRT, "Cardiac Wall Motion") = (F-32056, SRT, "Hypokinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (F-32056, SRT, "Hypokinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (R-0032F, SRT, "Moderate Hypokinesis")

2.5

(F-32050, SRT, "Cardiac Wall Motion") = (R-00370, SRT, "Severe Hypokinesis")

3

(F-32050, SRT, "Cardiac Wall Motion") = (F-30004, SRT, "Akinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (F-30004, SRT, "Akinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (F-30004, SRT, "Akinesis")

4

(F-32050, SRT, "Cardiac Wall Motion") = (F-32052, SRT, "Dyskinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (F-32052, SRT, "Dyskinesis")

(F-32050, SRT, "Cardiac Wall Motion") = (F-32052, SRT, "Dyskinesis")

5

(G-C504, SRT, "Associated Morphology") = (D3-10510, SRT, "Ventricular Aneurysm")

(G-C504, SRT, "Associated Morphology") = (D3-10510, SRT, "Ventricular Aneurysm")


TID 5220 Pediatric, Fetal and Congenital Cardiac Ultrasound Reports

This template forms the top of a content tree that allows an ultrasound application to describe the results of a Cardiac Ultrasound imaging procedure. It is instantiated at the root node.

Type:

Extensible

Order:

Significant

Root:

Yes

Table TID 5220. Pediatric, Fetal and Congenital Cardiac Ultrasound Reports

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DCID 12245 “Cardiac Ultrasound Report Titles”

1

M

Root node

2

>

HAS CONCEPT MOD

INCLUDE

DTID 1204 “Language of Content Item and Descendants”

1

M

3

>

HAS OBS CONTEXT

INCLUDE

DTID 1001 “Observation Context”

1

M

4

>

CONTAINS

CONTAINER

EV (121109, DCM, "Indications for Procedure")

1

U

5

>>

CONTAINS

CODE

EV (121071, DCM, "Finding")

1-n

U

DCID 12246 “Cardiac Ultrasound Indication for Study”

6

>>

CONTAINS

TEXT

EV (121071, DCM, "Finding")

1

U

7

>

CONTAINS

INCLUDE

DTID 3802 “Cardiovascular Patient History”

1

U

8

>

CONTAINS

INCLUDE

DTID 3602 “Cardiovascular Patient Characteristics”

1

U

9

>

CONTAINS

INCLUDE

DTID 5225 “Cardiac Ultrasound Fetal Characteristics”

1-n

U

No more than one inclusion per fetus

10

>

CONTAINS

INCLUDE

DTID 5226 “Cardiac Ultrasound Summary Section”

1

U

11

>

CONTAINS

INCLUDE

DTID 5227 “Cardiac Ultrasound Fetal Summary Section”

1-n

U

No more than one inclusion per fetus

12

>

CONTAINS

CONTAINER

EV (111028, DCM, "Image Library")

1

U

13

>>

CONTAINS

IMAGE

No purpose of reference

1-n

M

14

>

CONTAINS

INCLUDE

DTID 5221 “Cardiac Ultrasound Pediatric Echo Measurement Section”

1

U

15

>

CONTAINS

INCLUDE

DTID 5228 “Cardiac Ultrasound Fetal Measurement Section”

1-n

UC

For Fetal Report only.

No more than one inclusion per fetus


Content Item Descriptions

Row 3

For Fetal Report, this row establishes the subject context of the mother.

Row 7

For Fetal Report, this row will be the patient history of the mother.

Row 8

For Fetal Report, this row will be the Patient Characteristics for the mother.

Row 10

For Fetal Report, this row will be the Summary Section for the mother.

TID 5221 Cardiac Ultrasound Pediatric Echo Measurement Section

Type:

Extensible

Order:

Significant

Table TID 5221. Cardiac Ultrasound Pediatric Echo Measurement Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12282 “Cardiac Ultrasound Venous Return Systemic Finding Sites”

$MeasType = DCID 12264 “Cardiac Ultrasound Venous Return Systemic Measurements”

2

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12283 “Cardiac Ultrasound Venous Return Pulmonary Finding Sites”

$MeasType = DCID 12263 “Cardiac Ultrasound Venous Return Pulmonary Measurements”

3

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12284 “Cardiac Ultrasound Atria and Atrial Septum Finding Sites”

$MeasType = DCID 12265 “Cardiac Ultrasound Atria and Atrial Septum Measurements”

4

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12285 “Cardiac Ultrasound Atrioventricular Valves Finding Sites”

$MeasType = DCID 12268 “Cardiac Ultrasound Atrioventricular Valves Measurements”

5

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12286 “Cardiac Ultrasound Interventricular Septum Finding Sites”

$MeasType = DCID 12269 “Cardiac Ultrasound Interventricular Septum Measurements”

6

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12287 “Cardiac Ultrasound Ventricles Finding Sites”

$MeasType = DCID 12259 “Cardiac Ultrasound Ventricles Measurements”

8

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12288 “Cardiac Ultrasound Outflow Tracts Finding Sites”

$MeasType = DCID 12271 “Cardiac Ultrasound Outflow Tracts Measurements”

9

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12289 “Cardiac Ultrasound Semilunar Valves, Annulate and Sinuses Finding Sites”

$MeasType = DCID 12272 “Cardiac Ultrasound Semilunar Valves, Annulate and Sinuses Measurements”

10

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12290 “Cardiac Ultrasound Pulmonary Arteries Finding Sites”

$MeasType = DCID 12260 “Cardiac Ultrasound Pulmonary Artery”

11

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12291 “Cardiac Ultrasound Aorta Finding Sites”

$MeasType = DCID 12274 “Cardiac Ultrasound Aorta Measurements”

12

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12292 “Cardiac Ultrasound Coronary Arteries Finding Sites”

$MeasType = DCID 12275 “Cardiac Ultrasound Coronary Arteries Measurements”

13

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12293 “Cardiac Ultrasound Aortopulmonary Connections Finding Sites”

$MeasType = DCID 12276 “Cardiac Ultrasound Aorto Pulmonary Connections Measurements”

14

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = DCID 12294 “Cardiac Ultrasound Pericardium and Pleura Finding Sites”

$MeasType = DCID 12277 “Cardiac Ultrasound Pericardium and Pleura Measurements”


TID 5222 Pediatric, Fetal and Congenital Cardiac Ultrasound Section

This is a generic section heading Template for any of the anatomical headings. Measurements within a section heading appear as groups (by image mode or acquisition protocol).

Table TID 5222. Parameters

Parameter Name

Parameter Usage

$SectionSubject

The subject modifier of the section heading container

$MeasType

The concept name of the measurement


Type:

Extensible

Order:

Significant

Table TID 5222. Pediatric, Fetal and Congenital Cardiac Ultrasound Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

EV (G-C0E3, SRT, "Finding Site")

1

M

$SectionSubject

3

>>

HAS CONCEPT MOD

CODE

EV (P1-32006, SRT, "Heart valve replacement - prosthesis")

1

U

DCID 230 “Yes-No”

4

>

CONTAINS

CONTAINER

DT (125007, DCM, "Measurement Group")

1-n

M

5

>>

HAS CONCEPT MOD

CODE

EV (G-0373, SRT, "Image Mode")

1

U

BCID 12224 “Ultrasound Image Modes”

6

>>

HAS CONCEPT MOD

TEXT

DT (125203, DCM, "Acquisition Protocol")

1

U

7

>>

CONTAINS

INCLUDE

DTID 5223 “Pediatric, Fetal and Congenital Cardiac Ultrasound Measurement”

1-n

M

$Measurement = $MeasType

$Method = CID 12227 “Echocardiography Measurement Method”


TID 5223 Pediatric, Fetal and Congenital Cardiac Ultrasound Measurement

This Template provides for the post-coordination of a measurement with a variety of concept modifiers and acquisition context observations. When invoked from TID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”, the measurement concept is implicitly post-coordinated with the concept modifiers of the Measurement Group (TID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section” Rows 5 and 6), and with the Finding Site of the report section (TID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section” Row 2). The finding site may be further specified within this Template by the Target Site and Target Site Modifiers (CID 12280 “Cardiac Ultrasound Target Sites” and CID 12281 “Cardiac Ultrasound Target Site Modifiers”).

The implicit finding site inherited from TID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section” can be made explicit by using the same finding site concept in the Target Site (the measurement concept modifier), rather than a term from CID 12280 “Cardiac Ultrasound Target Sites”. This explicit post-coordination allows the use of one of the modifiers of CID 12281 “Cardiac Ultrasound Target Site Modifiers” to that finding site, as the Target Site Modifier requires an explicit Target Site in the measurement structure (TID 300 “Measurement” Rows 5 and 7). In fact, any child concept of the finding site in the SNOMED hierarchy may be used as the measurement Target Site.

The finding or target site may be identified by a concept from the SNOMED "clinical finding" or "morphological anomaly" hierarchies (e.g., D4-31220 "Atrial Septal Defect", or M-36700 "Effusion"), rather than the "anatomical structure" hierarchy. In this case, the meaning is inferred as "the anatomic location of the clinical finding or morphological anomaly, within the constraints of other implicit or explicit post-coordinated finding site concepts."

Note

Thus when TID 5221 “Cardiac Ultrasound Pediatric Echo Measurement Section” Row 14 invokes TID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section” with the section finding site concept (T-39000, SRT, "Pericardium"), and TID 5223 “Pediatric, Fetal and Congenital Cardiac Ultrasound Measurement” Row 1 applies the target site (M-36700, SRT, "Effusion"), the effective finding site is "pericardial effusion".

Table TID 5223. Parameters

Parameter Name

Parameter Usage

$Measurement

Coded term or Context Group for Concept Name of measurement

$Method

Value for Measurement Method


Type:

Extensible

Order:

Significant

Table TID 5223. Pediatric, Fetal and Congenital Cardiac Ultrasound Measurement

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

INCLUDE

DTID 300 “Measurement”

1

M

$Measurement = $Measurement

$Method = $Method

$TargetSite = BCID 12280 “Cardiac Ultrasound Target Sites”

$TargetSiteMod = BCID 12281 “Cardiac Ultrasound Target Site Modifiers”

$Derivation = DCID 3838 “Diameter Derivation”

2

>

HAS CONCEPT MOD

CODE

EV (121425, DCM, "Index")

1

U

DCID 3455 “Index Methods”

3

>

HAS CONCEPT MOD

CODE

EV (G-C048, SRT, "Flow Direction")

1

U

BCID 12221 “Flow Direction”

4

>

HAS CONCEPT MOD

CODE

EV (R-40899, SRT, "Respiratory Cycle Point")

1

U

DCID 12234 “Respiration State”

5

>

HAS CONCEPT MOD

CODE

EV (R-4089A, SRT, "Cardiac Cycle Point")

1

U

DCID 12233 “Cardiac Phase”

6

>

HAS ACQ CONTEXT

CODE

EV (G-0373, SRT, "Image Mode")

1

U

DCID 12224 “Ultrasound Image Modes”

7

>

HAS ACQ CONTEXT

CODE

EV (111031, DCM, "Image View")

1

U

BCID 12226 “Echocardiography Image View”


Content Item Descriptions

Row 1

For an index type of measurement, the concept name of this row 1 will still be the original measurement concept name; it is row 2 that gives the indication that row 1 is actually an index type of measurement. When this happens, the measurement value of row 1 should be a value after being indexed and the measurement unit of row 1 should be an index type of unit.

For example, to insert a "Stroke Volume Index" measurement to this SR object, the concept name of row 1 will be "Stroke Volume", its numerical value will be the calculation result of "Stroke Volume /BSA" and its units are "ml/cm2".

Row 2

When this row is available, the row 1 is an index calculation of the object.

TID 5225 Cardiac Ultrasound Fetal Characteristics

Contains a list of Fetus Specific characteristics.

Type:

Extensible

Order:

Significant

Table TID 5225. Cardiac Ultrasound Fetal Characteristics

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (125015, DCM, "Fetus Characteristics")

1

M

2

>

HAS OBS CONTEXT

INCLUDE

DTID 1008 “Subject Context, Fetus”

1

MC

IF this template is invoked more than once to describe more than one fetus.

3

>

CONTAINS

NUM

EV (18185-9, LN, "Gestational Age")

1

U

UNITS = DCID 7456 “Units of Measure for Age”

4

>

CONTAINS

DATE

EV (11778-8, LN, "EDD")

1

U

5

>

CONTAINS

NUM

EV (8867-4, LN, "Heart Rate")

1

U


TID 5226 Cardiac Ultrasound Summary Section

Comments and observations of the procedure of immediate clinical interest.

Type:

Extensible

Order:

Significant

Table TID 5226. Cardiac Ultrasound Summary Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121111, DCM, "Summary")

1

M

2

>

CONTAINS

CODE

EV (121071, DCM, "Finding")

1-n

MC

IF row 3 does not exist

BCID 12248 “Cardiac Ultrasound Summary Codes”

3

>

CONTAINS

TEXT

EV (121071, DCM, "Finding")

1-n

MC

IF row 2 does not exist

4

>

CONTAINS

CODE

EV (P0-009C3, SRT, "Surgical Procedure")

1-n

U

BCID 12247 “Pediatric, Fetal and Congenital Cardiac Surgical Interventions”


TID 5227 Cardiac Ultrasound Fetal Summary Section

Comments and observations of the procedure of immediate clinical interest.

Type:

Extensible

Order:

Significant

Table TID 5227. Cardiac Ultrasound Fetal Summary Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125008, DCM, "Fetus Summary")

1

M

2

>

HAS OBS CONTEXT

INCLUDE

DTID 1008 “Subject Context, Fetus”

1

MC

IF this template is invoked more than once to describe more than one fetus

3

>

CONTAINS

CODE

EV (121071, DCM, "Finding")

1-n

MC

IF row 4 does not exist

BCID 12249 “Cardiac Ultrasound Fetal Summary Codes”

4

>

CONTAINS

TEXT

EV (121071, DCM, "Finding")

1-n

MC

IF row 3 does not exist

5

>

CONTAINS

CODE

EV (P0-009C3, SRT, "Surgical Procedure")

1-n

U

BCID 12247 “Pediatric, Fetal and Congenital Cardiac Surgical Interventions”


TID 5228 Cardiac Ultrasound Fetal Measurement Section

Type:

Extensible

Order:

Significant

Table TID 5228. Cardiac Ultrasound Fetal Measurement Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (125016, DCM, "Fetal Measurements")

1

M

2

>

HAS OBS CONTEXT

INCLUDE

DTID 1008 “Subject Context, Fetus”

1

MC

IF this template is invoked more than once to describe more than one fetus.

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

U

$Measurement = DCID 12279 “Cardiac Ultrasound Fetal General Measurements”

4

>

CONTAINS

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = EV (T-F6845, SRT, "Ductus arteriosus")

$MeasType = DCID 12218 “Echocardiography Congenital”

5

>

CONTAINS

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = EV (T-F6806, SRT, "Ductus venosus")

$MeasType = DCID 12218 “Echocardiography Congenital”

6

>

CONTAINS

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = EV (T-F1810, SRT, "Umbilical artery")

$MeasType = DCID 12218 “Echocardiography Congenital”

7

>

CONTAINS

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = EV (T-D03B4, SRT, "Umbilical vein")

$MeasType = DCID 12218 “Echocardiography Congenital”

8

>

CONTAINS

INCLUDE

DTID 5222 “Pediatric, Fetal and Congenital Cardiac Ultrasound Section”

1-n

U

$SectionSubject = EV (T-45600, SRT, "Middle cerebral artery")

$MeasType = DCID 12218 “Echocardiography Congenital”