Cath Lab Clinical Report Templates
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## Cath Lab Clinical Report Templates

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

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 |  |

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