OB-GYN Report Templates 
Prev  A Structured Reporting Templates (Normative)  Next

OB-GYN Report Templates 

TID 5000 OB-GYN Ultrasound Procedure Report

This is the template for the root of the content tree for the OB-GYN ultrasound procedure report.

Type:

Extensible

Order:

Significant

Root:

Yes

Table TID 5000. OB-GYN Ultrasound Procedure Report

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (125000, DCM, "OB-GYN Ultrasound 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

INCLUDE

DTID 5001 “OB-GYN Patient Characteristics”

1

U

5

>

CONTAINS

CONTAINER

DT (111028, DCM, "Image Library")

1

U

6

>>

CONTAINS

IMAGE

No purpose of reference

1-n

M

7

>

CONTAINS

INCLUDE

DTID 5002 “OB-GYN Procedure Summary Section”

1

U

8

>

CONTAINS

INCLUDE

DTID 5004 “Fetal Biometry Ratio Section”

1-n

U

9

>

CONTAINS

INCLUDE

DTID 5005 “Fetal Biometry Section”

1-n

U

10

>

CONTAINS

INCLUDE

DTID 5006 “Fetal Long Bones Section”

1-n

U

11

>

CONTAINS

INCLUDE

DTID 5007 “Fetal Cranium Section”

1-n

U

12

>

CONTAINS

INCLUDE

DTID 5009 “Fetal Biophysical Profile Section”

1-n

U

13

>

CONTAINS

INCLUDE

DTID 5011 “Early Gestation Section”

1-n

U

14

>

CONTAINS

INCLUDE

DTID 5010 “Amniotic Sac Section”

1

U

15

>

CONTAINS

INCLUDE

DTID 5015 “Pelvis and Uterus Section”

1

U

16

>

CONTAINS

INCLUDE

DTID 5012 “Ovaries Section”

1

U

17

>

CONTAINS

INCLUDE

DTID 5013 “Follicles Section”

1

U

$Laterality = EV (G-A101, SRT, "Left")

$Number = EV (11879-4, LN, "Number of follicles in left ovary")

18

>

CONTAINS

INCLUDE

DTID 5013 “Follicles Section”

1

U

$Laterality = EV (G-A100, SRT, "Right")

$Number = EV (11880-2, LN, "Number of follicles in right ovary")

19

>

CONTAINS

CONTAINER

EV (121070, DCM, "Findings")

1-n

U

20

>>

HAS CONCEPT MOD

CODE

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

1

M

EV (T-F6800, SRT, "Embryonic Vascular Structure")

21

>>

CONTAINS

INCLUDE

DTID 5025 “OB-GYN Fetal Vascular Ultrasound Measurement Group”

1

M

$AnatomyGroup = DCID 12141 “Fetal Vasculature Anatomical Location”

22

>

CONTAINS

CONTAINER

EV (121070, DCM, "Findings")

1-n

U

23

>>

HAS CONCEPT MOD

CODE

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

1

M

EV (T-D6007, SRT, "Pelvic Vascular Structure")

24

>>

CONTAINS

INCLUDE

DTID 5026 “OB-GYN Pelvic Vascular Ultrasound Measurement Group”

1

M

$AnatomyGroup = DCID 12140 “Pelvic Vasculature Anatomical Location”


TID 5001 OB-GYN 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 5001. OB-GYN 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

TEXT

EV (121106, DCM, "Comment")

1

U

3

>

CONTAINS

NUM

EV (8302-2, LN, "Patient Height")

1

U

4

>

CONTAINS

NUM

EV (29463-7, LN, "Patient Weight")

1

U

5

>

CONTAINS

NUM

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

1

U

6

>

CONTAINS

NUM

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

1

U

7

>

CONTAINS

NUM

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

1

U

8

>

CONTAINS

NUM

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

1

U


TID 5002 OB-GYN Procedure Summary Section

Observations of the procedure of immediate clinical interest.

Type:

Extensible

Order:

Significant

Table TID 5002. OB-GYN Procedure Summary Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (121111, DCM, "Summary")

1

M

2

>

CONTAINS

DATE

DCID 12003 “OB-GYN Dates”

1-n

U

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

U

$Measurement = BCID 12018 “OB-GYN Summary”

4

>

CONTAINS

TEXT

EV (121106, DCM, "Comment")

1-n

U

5

>>

INCLUDE

DTID 320 “Image or Spatial Coordinates”

1-n

U

6

>

CONTAINS

INCLUDE

BTID 5003 “OB-GYN Fetus Summary”

1-n

UC

No more than 1 inclusion per fetus


TID 5003 OB-GYN Fetus Summary

The Fetus Summary template is a container for summary data of a fetus.

Type:

Extensible

Order:

Significant

Table TID 5003. OB-GYN Procedure Fetus Summary

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

TEXT

EV (121106, DCM, "Comment")

1-n

U

4

>>

INCLUDE

DTID 320 “Image or Spatial Coordinates”

1

U

5

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

U

$Measurement = DCID 12019 “OB-GYN Fetus Summary”

$Equation = DCID 12012 “OB Equations and Tables”


TID 5004 Fetal Biometry Ratio Section

The Fetal Biometry Section Ratio template is a container for common biometric ratios.

Type:

Extensible

Order:

Significant

Table TID 5004. Fetal Biometry Ratio Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125001, DCM, "Fetal Biometry Ratios")

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

DCID 12004 “Fetal Biometry Ratios”

1-n

M

4

>>

R-INFERRED FROM

NUM

2

U

5

>>

HAS PROPERTIES

INCLUDE

DTID 312 “Normal Range Properties”

1

U


Content Item Descriptions

Row 3

Numeric ratio related to fetal growth

Row 4

Reference to the numerator and denominator of the ratio.

TID 5005 Fetal Biometry Section

The Fetal Biometry Section template is a container for common biometric groups.

Type:

Extensible

Order:

Significant

Table TID 5005. Fetal Biometry Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125002, DCM, "Fetal Biometry")

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 5008 “Fetal Biometry Group”

1-n

M

$BiometryType = MemberOf {DCID 12005 “Fetal Biometry Measurements”


Content Item Descriptions

Row 3

The group of measurements. Only one group per biometry type.

TID 5006 Fetal Long Bones Section

The Long Bones template is a container for biometric data of long bones.

Type:

Extensible

Order:

Significant

Table TID 5006. Fetal Long Bones Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125003, DCM, "Fetal Long Bones")

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 5008 “Fetal Biometry Group”

1-n

M

$BiometryType = MemberOf {DCID 12006 “Fetal Long Bones Biometry Measurements”


Content Item Descriptions

Row 3

The group of measurements. Only one group per biometry type.

TID 5007 Fetal Cranium Section

The Fetal Cranium template is a container for groups of biometric data of the fetal cranium.

Type:

Extensible

Order:

Significant

Table TID 5007. Fetal Cranium Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125004, DCM, "Fetal Cranium")

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 5008 “Fetal Biometry Group”

1-n

M

$BiometryType = MemberOf {DCID 12007 “Fetal Cranium”


Content Item Descriptions

Row 3

The group of measurements. Only one group per biometry type.

TID 5008 Fetal Biometry Group

The Biometry Group template is container for a biometric value and its associated growth metrics.

Table TID 5008. Parameters

Parameter Name

Parameter Usage

$BiometryType

The concept name of the biometry measurement

Type:

Extensible

Order:

Significant

Table TID 5008. Fetal Biometry Group

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125005, DCM, "Biometry Group")

1

M

2

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

MC

At least one of row 2 and 3 shall be present

$Measurement = $BiometryType

$Derivation = DCID 3627 “Measurement Type”

3

>

CONTAINS

NUM

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

1

MC

At least one of row 2 and 3 shall be present

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

4

>>

INFERRED FROM

CODE

DCID 228 “Equation or Table”

1

U

DCID 12013 “Gestational Age Equations and Tables”

5

>>

R-INFERRED FROM

NUM

1-n

U

6

>>

HAS PROPERTIES

NUM

DCID 226 “Population Statistical Descriptors”

1-n

U

7

>

CONTAINS

NUM

DCID 12017 “Growth Distribution Rank”

1

U

8

>>

INFERRED FROM

CODE

DCID 228 “Equation or Table”

1

U

DCID 12015 “Fetal Growth Equations and Tables”


Content Item Descriptions

Row 1

Container to segregate biometry data by measurement type

Row 2

The discrete measurements of the biometry type including derived measurements such as mean. One of the measurements may be flagged as selected for derived measurements.

Row 3

The estimated gestational age derived from an equation or table based on the explicitly referenced R-INFERRED FROM content item, selected measurement or mean, in that order of preference.

Row 4

The reference that defines the equation or table of GA derivation

Row 6

The uncertainty/confidence limits of the gestational age

Row 7

Expresses the rank of the selected or mean measurement of row 2 relative to the distribution specified in row 8.

Row 8

This row specifies the CODE reference used to compute the percentile or Z-score.

TID 5009 Fetal Biophysical Profile Section

This template encodes scoring observations for fetal well-being evaluation as described by Manning, Antepartum Fetal Evaluation: Development of a Fetal Biophysical Profile Score, Am. J Obsetet Gynecol, 1980;136:787.

Type:

Extensible

Order:

Significant

Table TID 5009. Fetal Biophysical Profile Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125006, DCM, "Biophysical Profile")

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 (11631-9, LN, "Gross Body Movement")

1

MC

At least one of row 3-7 shall be present

UNITS = DT ({0:2}, UCUM, "range 0:2")

4

>

CONTAINS

NUM

EV (11632-7, LN, "Fetal Breathing")

1

MC

At least one of row 3-7 shall be present

UNITS = DT ({0:2}, UCUM, "range 0:2")

5

>

CONTAINS

NUM

EV (11635-0, LN, "Fetal Tone")

1

MC

At least one of row 3-7 shall be present

UNITS = DT ({0:2}, UCUM, "range 0:2")

6

>

CONTAINS

NUM

EV (11635-5, LN, "Fetal Heart Reactivity")

1

MC

At least one of row 3-7 shall be present

UNITS = DT ({0:2}, UCUM, "range 0:2")

7

>

CONTAINS

NUM

EV (11630-1, LN, "Amniotic Fluid Volume")

1

MC

At least one of row 3-7 shall be present

UNITS = DT ({0:2}, UCUM, "range 0:2")

8

>

CONTAINS

NUM

DT (11634-3, LN, "Biophysical Profile Sum Score")

1

U


Content Item Descriptions

Row 3-7

The numeric profile score of range 0-2

Row 8

The sum of rows 3-7. The range is from 0 to the maximum possible score according the items scored in rows 3-7.

TID 5010 Amniotic Sac Section

This template specifies a container for amniotic sac quadrant diameters and a derived index.

Type:

Extensible

Order:

Significant

Table TID 5010. Amniotic Sac Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

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

1

M

DT (T-F1300, SRT, "Amniotic Sac")

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1

M

$Measurement = DT (11627-7, LN, "Amniotic Fluid Index")

4

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

4

U

$Measurement = DCID 12008 “OB-GYN Amniotic Sac”


Content Item Descriptions

Row 3

The sum of the 4 quadrant diameters

Row 4

The four amniotic sac quadrant diameters

TID 5011 Early Gestation Section

The Early Gestation Section template is a container for common, first trimester biometric groups.

Type:

Extensible

Order:

Significant

Table TID 5011. Early Gestation Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125009, DCM, "Early Gestation")

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 5008 “Fetal Biometry Group”

1-n

M

$BiometryType = Member of {DCID 12009 “Early Gestation Biometry Measurements”}

TID 5012 Ovaries Section

This template contains metrics of ovary size.

Type:

Extensible

Order:

Significant

Table TID 5012. Ovaries Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

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

1

M

DT (T-87000, SRT, "Ovary")

3

>

CONTAINS

INCLUDE

DTID 5016 “LWH Volume Group”

1

U

$GroupName = EV (T-87000, SRT, "Ovary")

$Width = EV (11829-9, LN, "Left Ovary Width")

$Length = EV (11840-6, LN, "Left Ovary Length")

$Height = EV (11857-0, LN, "Left Ovary Height")

$Volume = EV (12164-0, LN, "Left Ovary Volume")

4

>

CONTAINS

INCLUDE

DTID 5016 “LWH Volume Group”

1

U

$GroupName = EV (T-87000, SRT, "Ovary")

$Width = EV (11830-7, LN, "Right Ovary Width")

$Length = EV (11841-4, LN, "Right Ovary Length")

$Height = EV (11858-8, LN, "Right Ovary Height")

$Volume = EV (12165-7, LN, "Right Ovary Volume")


TID 5013 Follicles Section

This template contains follicle metrics for left or right ovarian follicles.

Table TID 5013. Parameters

Parameter Name

Parameter Usage

$Laterality

Ovary laterality

$Number

The number of follicles

Type:

Extensible

Order:

Significant

Table TID 5013. Follicles Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (121070, DCM, "Findings")

1

M

2

>

HAS CONCEPT MOD

CODE

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

1

M

DT (T-87600, SRT, "Ovarian Follicle")

3

>

HAS CONCEPT MOD

CODE

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

1

M

$Laterality

4

>

CONTAINS

NUM

$Number

1

U

5

>

CONTAINS

INCLUDE

DTID 5014 “Follicle Measurement Group”

1-n

U


TID 5014 Follicle Measurement Group

This template contains metrics for one ovarian follicle.

Type:

Extensible

Order:

Significant

Table TID 5014. Follicle Measurement Group

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (125007, DCM, "Measurement Group")

1

M

2

>

HAS OBS CONTEXT

TEXT

EV (125010, DCM, "Identifier")

1

U

Unique among all groups of same laterality

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1

U

$Measurement = EV (G-D705, SRT, "Volume")

4

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

U

$Measurement = EV (11793-7, LN, "Follicle Diameter")

$Derivation = DCID 3627 “Measurement Type”


TID 5015 Pelvis and Uterus Section

This template contains general measurements in the pelvis and uterus.

Type:

Extensible

Order:

Significant

Table TID 5015. Pelvis and Uterus Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

DT (125011, DCM, "Pelvis and Uterus")

1

M

2

>

CONTAINS

INCLUDE

DTID 5016 “LWH Volume Group”

1

U

$GroupName = EV (T-83000, SRT, "Uterus")

$Width = EV (11865-3, LN, "Uterus Width")

$Length = EV (11842-2, LN, "Uterus Length")

$Height = EV (11859-6, LN, "Uterus Height")

$Volume = EV (33192-6, LN, "Uterus Volume")

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

U

$Measurement = DCID 12011 “Ultrasound Pelvis and Uterus”

$Derivation = DCID 3627 “Measurement Type”


TID 5016 LWH Volume Group

This template is a container for a group of measurements that assess the size of an anatomical structure using a volume derived from perpendicular diameters.

Table TID 5016. Parameters

Parameter Name

Parameter Usage

$GroupName

The name of the volume group

$Volume

Concept name of volume measurement

$Length

Concept name of length measurement

$Width

Concept name of width measurement

$Height

Concept name of height measurement

Type:

Extensible

Order:

Significant

Table TID 5016. LWH Volume Group

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

$GroupName

1

M

2

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1

MC

At least one of row 2, 3, 4, 5 shall be present

$Measurement = $Volume

3

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

MC

At least one of row 2, 3, 4, 5 shall be present

$Measurement = $Length

$Derivation = DCID 3627 “Measurement Type”

4

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

MC

At least one of row 2, 3, 4, 5 shall be present

$Measurement = $Width

$Derivation = DCID 3627 “Measurement Type”

5

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

MC

At least one of row 2, 3, 4, 5 shall be present

$Measurement = $Height

$Derivation = DCID 3627 “Measurement Type”


TID 5025 OB-GYN Fetal Vascular Ultrasound Measurement Group

This template is an anatomy specific container of OB-GYN fetal vascular measurements.

Table TID 5025. Parameters

Parameter Name

Parameter Usage

$AnatomyGroup

The concept name of the vascular anatomy

Type:

Extensible

Order:

Significant

Table TID 5025. OB-GYN Fetal Vascular Ultrasound Measurement Group

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

$AnatomyGroup

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

>

HAS CONCEPT MOD

CODE

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

1

MC

IFF anatomy has laterality

DCID 244 “Laterality”

4

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

M

$MeasType = DCID 12119 “Vascular Ultrasound Property”

$Derivation = DCID 3627 “Measurement Type”


Content Item Descriptions

Anatomy Group

Specifies the anatomical context of the observations in the group.

TID 5026 OB-GYN Pelvic Vascular Ultrasound Measurement Group

This template is an anatomy specific container of OB-GYN pelvic vascular measurements.

Table TID 5026. Parameters

Parameter Name

Parameter Usage

$AnatomyGroup

The concept name of the vascular anatomy

Type:

Extensible

Order:

Significant

Table TID 5026. OB-GYN Pelvic Vascular Ultrasound Measurement Group

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

$AnatomyGroup

1

M

2

>

HAS CONCEPT MOD

CODE

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

1

MC

IFF anatomy has laterality

DCID 244 “Laterality”

3

>

HAS CONCEPT MOD

TEXT

EV (112050, DCM, "Anatomic Identifier")

1

U

4

>

CONTAINS

INCLUDE

DTID 300 “Measurement”

1-n

M

$MeasType = DCID 12119 “Vascular Ultrasound Property”

$Derivation = DCID 3627 “Measurement Type”

5

>>

HAS CONCEPT MOD

CODE

EV (125105, DCM, "Measurement Orientation")

1

U

DCID 12118 “Measurement Orientation”

6

>>

HAS PROPERTIES

NUM

EV (125106, DCM, "Doppler Angle")

1

U

UNIT = EV (deg, UCUM, "deg")

7

>>

HAS PROPERTIES

NUM

EV (125107, DCM, "Sample Volume Depth")

1

U

UNIT = EV (cm, UCUM, "cm")

Content Item Descriptions

Row 1

Specifies the anatomical context of the observations in the group.

Row 3

Differentiates between multiple structures such as the two umbilical arteries.
Prev  Up  Next
Breast Imaging Report Templates   Home  Vascular Ultrasound Report Templates