Relevant Patient Information Templates 

TID 9000 Relevant Patient Information for Breast Imaging

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

Type:

Extensible

Order:

Significant

Table TID 9000. Relevant Patient Information for Breast Imaging


TID 9001 Gynecological History

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

Type:

Extensible

Order:

Significant

Table TID 9001. Gynecological History

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (R-20767, SRT, "Gynecological History")

1

M

2

>

HAS OBS CONTEXT

CODE

EV (111534, DCM, "Role of person reporting")

1

U

DCID 7450 “Person Roles”

3

>

CONTAINS

DATE

EV (11955-2, LN, "Date of last menstrual period")

1

U

4

>

CONTAINS

NUM

EV (111518, DCM, "Age when first menstrual period occurred")

1

U

UNITS = EV (a, UCUM, "Year")

5

>

CONTAINS

NUM

EV (111519, DCM, "Age at First Full Term Pregnancy")

1

U

UNITS = EV (a, UCUM, "Year")

6

>

CONTAINS

NUM

EV (11977-6, LN, "Para")

1

U

UNITS = EV (1, UCUM, "no units")

7

>

CONTAINS

NUM

EV (11639-2, LN, "Term")

1

U

UNITS = EV (1, UCUM, "no units")

8

>

CONTAINS

NUM

EV (11637-6, LN, "Preterm")

1

U

UNITS = EV (1, UCUM, "no units")

9

>

CONTAINS

NUM

EV (11636-8, LN, "Live Births")

1

U

UNITS = EV (1, UCUM, "no units")

10

>

CONTAINS

NUM

EV (111593, DCM, "LBW or IUGR")

1

U

UNITS = EV (1, UCUM, "no units")

11

>

CONTAINS

NUM

EV (11996-6, LN, "Gravida")

1

U

UNITS = EV (1, UCUM, "no units")

12

>

CONTAINS

NUM

EV (11612-9, LN, "Aborta")

1

U

UNITS = EV (1, UCUM, "no units")

13

>

CONTAINS

NUM

EV (33065-4, LN, "Ectopic Pregnancies")

1

U

UNITS = EV (1, UCUM, "no units")

14

>

CONTAINS

NUM

EV (111520, DCM, "Age at Menopause")

1

U

UNITS = EV (a, UCUM, "Year")

15

>

CONTAINS

NUM

EV (111521, DCM, "Age when hysterectomy performed")

1

U

UNITS = EV (a, UCUM, "Year")

16

>>

HAS CONCEPT MOD

CODE

EV (R-404ED, SRT, "Extent")

1

U

EV (R-404F1, SRT, "Complete")

EV (R-404FE, SRT, "Partial")

17

>

CONTAINS

NUM

EV (111522, DCM, "Age when left ovary removed")

1

U

UNITS = EV (a, UCUM, "Year")

18

>

CONTAINS

NUM

EV (111523, DCM, "Age when right ovary removed")

1

U

UNITS = EV (a, UCUM, "Year")

19

>

CONTAINS

CODE

EV (111543, DCM, "Breast feeding history")

1

U

DCID 230 “Yes-No”

20

>>

HAS PROPERTIES

NUM

EV (111544, DCM, "Average breast feeding period")

1

U

UNITS = EV (wk, UCUM, "Week")

21

>

CONTAINS

CODE

EV (111532, DCM, "Pregnancy Status")

1

U

DCID 6096 “Pregnancy Status”

22

>

CONTAINS

CODE

EV (111391, DCM, "Menstrual Cycle Phase")

1

U

DCID 6163 “Menstrual Cycle Phase”


TID 9002 Medication, Substance, Environmental Exposure

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

Table TID 9002. Parameters

Parameter Name

Parameter Usage

$ContainerConcept

Coded term for the concept name of the CONTAINER, identifying it as medication, substance, or environmental exposure history.

$CodeConcept

Coded term for the concept name of the CODE, identifying it as medication, substance, or environmental exposure.

$CodeValue

Coded term or Context Group for value of the medication, substance, or environmental exposure.


Type:

Extensible

Order:

Significant

Table TID 9002. Medication, Substance, Environmental Exposure

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

$ContainerConcept

1

M

2

>

CONTAINS

CODE

$CodeConcept

1-n

M

$CodeValue

3

>>

HAS CONCEPT MOD

CODE

EV (G-C032, SRT, "Classification")

1

U

4

>>

HAS OBS CONTEXT

CODE

EV (111534, DCM, "Role of person reporting")

1

U

DCID 7450 “Person Roles”

5

>>

HAS PROPERTIES

NUM

EV (111524, DCM, "Age Started")

1

U

UNITS = EV (a, UCUM, "Year")

6

>>

HAS PROPERTIES

NUM

EV (111525, DCM, "Age Ended")

1

U

UNITS = EV (a, UCUM, "Year")

7

>>

HAS PROPERTIES

DATETIME

EV (111526, DCM, "DateTime Started")

1

U

8

>>

HAS PROPERTIES

DATETIME

EV (111527, DCM, "DateTime Ended")

1

U

9

>>

HAS PROPERTIES

NUM

EV (G-7290, SRT, "Duration")

1

U

UNITS = DCID 6046 “Units of Follow-up Interval”

10

>>

HAS PROPERTIES

CODE

EV (111528, DCM, "Ongoing")

1

U

DCID 230 “Yes-No”

11

>>

HAS PROPERTIES

TEXT

EV (111529, DCM, "Brand Name")

1

U

12

>>

HAS PROPERTIES

NUM

DCID 6092 “Quantitative Concepts for Usage, Exposure”

1

U

The unit of measure shall be quantity per unit of time

13

>>

HAS PROPERTIES

CODE

DCID 6093 “Qualitative Concepts for Usage, Exposure Amount”

1

U

DCID 6090 “Relative Usage, Exposure Amount”

14

>>

HAS PROPERTIES

CODE

DCID 6094 “Qualitative Concepts for Usage, Exposure Frequency”

1

U

DCID 6091 “Relative Frequency of Event Values”


Content Item Descriptions

Row 3 "Classification"

No context group is provided for the value set, but it is recommended that values from a standard external coding scheme, such as SRT or NDC, be used.

Rows 13 & 14

If both of these content items are instantiated, the concept names selected for each should match. For example, use "Relative dose amount" as the concept name for row 13 with "Relative dose frequency" as the concept name for row 14.

TID 9003 Previous Procedure

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

Table TID 9003. Parameters

Parameter Name

Parameter Usage

$ProcedureList

Coded term or Context Group for value of Previous Procedure

$ProcedureModifier

Coded term or Context Group for value of Previous Procedure Modifier

$NumConceptName

Coded term or Context Group for the concept name of a numeric property of the Previous Procedure

$LateralityValue

Coded term or Context Group for value of Laterality

$ProcedureResult

Coded term or Context Group for value of Result of Procedure

$ComplicationValue

Coded term or Context Group for value of Complication


Type:

Extensible

Order:

Significant

Table TID 9003. Previous Procedure

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111513, DCM, "Relevant Previous Procedures")

1

M

2

>

CONTAINS

CODE

EV (111531, DCM, "Previous Procedure")

1-n

M

$ProcedureList

3

>>

HAS CONCEPT MOD

CODE

EV (111464, DCM, "Procedure Modifier")

1-n

U

$ProcedureModifier

4

>>

HAS OBS CONTEXT

CODE

EV (111534, DCM, "Role of person reporting")

1

U

DCID 7450 “Person Roles”

5

>>

HAS PROPERTIES

NUM

$NumConceptName

1-n

U

6

>>

HAS PROPERTIES

CODE

EV (G-C171, SRT, "Laterality")

1

U

$LateralityValue

7

>>

HAS PROPERTIES

DATETIME

EV (122146, DCM, "Procedure DateTime")

1

UC

XOR row 8

8

>>

HAS PROPERTIES

CODE

EV (111395, DCM, "Estimated Timeframe")

1

UC

XOR row 7

BCID 6164 “Time Intervals”

9

>>

HAS PROPERTIES

NUM

EV (R-42009, SRT, "Number of occurrences")

1

U

UNITS = EV (1, UCUM, "no units")

10

>>

HAS PROPERTIES

CODE

EV (DD-60002, SRT, "Complication of procedure")

1-n

U

$ComplicationValue

11

>>>

HAS PROPERTIES

CODE

EV (111466, DCM, "Severity of Complication")

1

U

DCID 251 “Severity of Complication”

12

>>

HAS PROPERTIES

CODE

EV (122177, DCM, "Procedure Result")

1

U

$ProcedureResult

13

>>

HAS PROPERTIES

INCLUDE

DTID 4207 “Breast Imaging Pathology Results”

1-n

U


TID 9004 Indicated Problem

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

Table TID 9004. Parameters

Parameter Name

Parameter Usage

$ProblemList

Coded term or Context Group for value of Indicated Problem

$LateralityValue

Coded term or Context Group for value of Laterality

$LocationValue

Coded term or Context Group for value of Location


Type:

Extensible

Order:

Significant

Table TID 9004. Indicated Problem

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (11450-4, LN, "Problem List")

1

M

2

>

CONTAINS

CODE

EV (111533, DCM, "Indicated Problem")

1-n

M

$ProblemList

3

>>

HAS OBS CONTEXT

CODE

EV (111534, DCM, "Role of person reporting")

1

U

DCID 7450 “Person Roles”

4

>>

HAS OBS CONTEXT

DATETIME

EV (111535, DCM, "DateTime problem observed")

1

U

5

>>

HAS PROPERTIES

CODE

EV (G-C171, SRT, "Laterality")

1

U

$LateralityValue

6

>>

HAS PROPERTIES

CODE

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

1

U

$LocationValue

7

>>

HAS PROPERTIES

NUM

EV (G-7290, SRT, "Duration")

1

U

8

>>

HAS PROPERTIES

CODE

EV (R-407E7, SRT, "Frequency")

1

U

DCID 6091 “Relative Frequency of Event Values”

9

>>

HAS PROPERTIES

DATETIME

EV (111536, DCM, "DateTime of last evaluation")

1

U

10

>>

HAS PROPERTIES

TEXT

EV (121106, DCM, "Comment")

1

U


TID 9005 Risk Factor

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

Table TID 9005. Parameters

Parameter Name

Parameter Usage

$RiskList

Coded term or Context Group for value of Risk Factor

$FamilyList

Coded term or Context Group for value of Family Member with Risk Factor


Type:

Extensible

Order:

Significant

Table TID 9005. Risk Factor

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111515, DCM, "Relevant Risk Factors")

1

M

2

>

CONTAINS

CODE

EV (F-01500, SRT, "Risk factor")

1-n

M

$RiskList

3

>>

HAS CONCEPT MOD

CODE

EV (111530, DCM, "Risk Factor modifier")

1

U

EV (G-0002, SRT, "Family history of")

4

>>

HAS PROPERTIES

NUM

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

1

UC

IFF value of row 2 is (G-0305, SRT, "History of - premature delivery")

5

>>

HAS OBS CONTEXT

CODE

EV (111534, DCM, "Role of person reporting")

1

U

DCID 7450 “Person Roles”

6

>>

HAS PROPERTIES

NUM

EV (111538, DCM, "Age at Occurrence")

1

U

UNITS = EV (a, UCUM, "Year")

7

>>

HAS PROPERTIES

NUM

EV (G-7290, SRT, "Duration")

1

U

UNITS = DCID 6046 “Units of Follow-up Interval”

8

>>

HAS PROPERTIES

TEXT

EV (121106, DCM, "Comment")

1

U

9

>>

INFERRED FROM

CODE

EV (111537, DCM, "Family Member with Risk Factor")

1-n

U

$FamilyList

10

>>>

HAS PROPERTIES

NUM

EV (111538, DCM, "Age at Occurrence")

1

U

UNITS = EV (a, UCUM, "Year")

11

>>>

HAS CONCEPT MOD

CODE

EV (111539, DCM, "Menopausal phase")

1

U

DCID 6086 “Menopausal Phase”

12

>>>

HAS CONCEPT MOD

CODE

EV (111540, DCM, "Side of Family")

1

U

DCID 6097 “Side of Family”


TID 9006 Obstetric History

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

Type:

Extensible

Order:

Significant

Table TID 9006. Obstetric History

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINS

CONTAINER

EV (R-20658, SRT, "Obstetric History")

1

M

2

>

CONTAINS

DATE

DCID 12003 “OB-GYN Dates”

1-n

U

3

>

CONTAINS

NUM

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

1

U

UNITS = EV (d, UCUM, "day")

4

>

CONTAINS

TEXT

EV (121106, DCM, "Comment")

1-n

U


Content Item Descriptions

Row 3 "Gestational Age"

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

TID 9007 General Relevant Patient Information

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

Type:

Extensible

Order:

Significant

Table TID 9007. General Relevant Patient Information

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111517, DCM, "Relevant Patient Information")

1

M

2

>

HAS CONCEPT MOD

INCLUDE

DTID 1204 “Language of Content Item and Descendants”

1

M

3

>

CONTAINS

INCLUDE

DTID 3114 “Patient Assessment”

1

U

4

>

CONTAINS

INCLUDE

DTID 9002 “Medication, Substance, Environmental Exposure”

1

U

$ContainerConcept = EV (10160-0, LN, "History Of Medication Use")

$CodeConcept = EV (111516, DCM, "Medication Type")

5

>

CONTAINS

INCLUDE

DTID 9002 “Medication, Substance, Environmental Exposure”

1

U

$ContainerConcept = EV (111545, DCM, "Substance Use History")

$CodeConcept = EV (111546, DCM, "Used Substance Type")

$CodeValue = BCID 6089 “Substances”

6

>

CONTAINS

INCLUDE

DTID 9002 “Medication, Substance, Environmental Exposure”

1

U

$ContainerConcept = EV (111547, DCM, "Environmental Exposure History")

$CodeConcept = EV (111548, DCM, "Environmental Factor")

7

>

CONTAINS

INCLUDE

DTID 9003 “Previous Procedure”

1

U

$LateralityValue = BCID 244 "Laterality"

8

>

CONTAINS

INCLUDE

DTID 9004 “Indicated Problem”

1

U

$LateralityValue = BCID 244 "Laterality"

9

>

CONTAINS

INCLUDE

DTID 9005 “Risk Factor”

1

U

$RiskList = BCID 6087 “General Risk Factors”

$FamilyList = DCID 7451 “Family Member”

10

>

CONTAINS

INCLUDE

DTID 9001 “Gynecological History”

1

U

11

>

CONTAINS

INCLUDE

DTID 9006 “Obstetric History”

1

U

12

>

CONTAINS

INCLUDE

DTID 3802 “Cardiovascular Patient History”

1

U

13

>

CONTAINS

INCLUDE

DTID 351 “Previous Reports”

1

U