The following are simple, non-comprehensive illustrations of report sections.
The following example shows the highest level of content items for a second or third trimester OB exam. Subsequent examples show details of section content,
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.1 |
Language of Content Item and Descendants |
English |
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1.2 |
Subject Name |
Jane Doe |
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1.3 |
Subject ID |
123-45-6789 |
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1.4 |
Procedure Study Instance UID |
1.2.842.111724.7678.32.34 |
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1.5 |
Procedure Study Component UID |
1.2.842.111724.7678.55.34 |
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1.6 |
Procedure Accession Number |
20011007-21 |
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1.7 |
Image Library |
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1.7.1 |
IMAGE 1 |
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1.7.2 |
IMAGE 2 |
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1.7.n |
IMAGE N |
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1.8 |
Patient Characteristics |
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1.8.n |
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1.9 |
Summary |
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1.9.n |
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1.10 |
Fetal Biometry Ratios |
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1.10.n |
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1.11 |
Long Bones |
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1.11.n |
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1.12 |
Fetal Cranium |
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1.12.n |
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1.13 |
Biophysical Profile |
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1.13.n |
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1.14 |
Amniotic Sac |
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|
1.14.n |
The following example shows the highest level of content items for a GYN exam. Subsequent examples show details of section content.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.1 |
Subject Name |
Jane Doe |
|
|
1.2 |
Subject ID |
123-45-6789 |
|
|
1.3 |
Image Library |
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|
1.3.1 |
IMAGE 1 |
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1.3.2 |
IMAGE 2 |
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1.3.n |
IMAGE N |
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1.4 |
Patient Characteristics |
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|
1.4.n |
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1.5 |
Findings |
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1.5.1 |
Findings Site |
Ovary |
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1.5.n |
|||
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1.6 |
Findings |
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1.6.1 |
Findings Site |
Ovarian Follicle |
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1.6.2 |
Laterality |
Left |
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1.6.n |
|||
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1.7 |
Findings |
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1.7.1 |
Findings Site |
Ovarian Follicle |
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1.7.2 |
Laterality |
Right |
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|
1.7.n |
|||
|
1.8 |
Pelvis and Uterus |
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|
1.8.n |
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
…. |
|||
|
1.8 |
Patient Characteristics |
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|
1.8.1 |
Gravida |
5 |
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1.8.2 |
Para |
3 |
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1.8.3 |
Aborta |
2 |
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1.8.4 |
Ectopic Pregnancies |
1 |
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1.9 |
Summary |
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|
1.9.1 |
LMP |
20010101 |
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1.9.2 |
EDD |
20010914 |
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1.9.3 |
EDD from LMP |
20010914 |
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1.9.4 |
EDD from average ultrasound age |
20010907 |
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1.9.5 |
Gestational age by ovulation date |
185 d |
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1.9.6 |
Fetus Summary |
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1.9.6.1 |
EFW |
2222 g |
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1.9.6.1.1 |
+/-, range of measurement uncertainty |
200 g |
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1.9.6.1.2 |
Equation |
EFW by AC, BPD, Hadlock 1984 |
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1.9.6.2 |
Comment |
Enlarged cisterna magna |
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1.9.6.3 |
Comment |
Choroid plexus cyst |
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
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|
1.5 |
Summary |
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|
1.5.1 |
EDD from LMP |
20020325 |
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1.5.2 |
Fetus Summary |
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1.5.2.1 |
Fetus ID |
A |
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1.5.2.2 |
EFW |
1.6 Kg |
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|
1.5.2.2.1 |
Equation |
EFW by AC, BPD, Hadlock 1984 |
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|
1.5.2.2.2 |
+/-, range of measurement uncertainty |
160g |
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|
1.5.2.3 |
Fetal Heart Rate |
120 {H.B.}/min |
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|
1.5.3 |
Fetus Summary |
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|
1.5.3.1 |
Fetus ID |
B |
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1.5.3.2 |
Comment |
Choroid plexus cyst |
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1.5.3.3 |
EFW |
1.4 kg |
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1.5.3.3.1 |
Equation |
EFW by AC, BPD, Hadlock 1984 |
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1.5.3.3.2 |
+/-, range of measurement uncertainty |
140 g |
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1.5.3.4 |
Fetal Heart Rate |
135 {H.B.}/min |
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|
1.6 |
Biophysical Profile |
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|
1.6.1 |
Fetus ID |
A |
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|
1.6.n |
… |
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1.7 |
Biophysical Profile |
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1.7.1 |
Fetus ID |
B |
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|
1.7.n |
… |
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
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|
1.9 |
Biophysical Profile |
||
|
1.9.1 |
Gross Body Movement |
2 {0:2} |
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1.9.2 |
Fetal Breathing |
2 {0:2} |
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1.9.3 |
Fetal Tone |
2 {0:2} |
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1.9.4 |
Fetal Heart Reactivity |
2 {0:2} |
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1.9.5 |
Amniotic Fluid Volume |
2 {0:2} |
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1.9.6 |
Biophysical Profile Sum Score |
10 {0:10} |
Optionally, but not shown, the ratios may have by-reference, inferred-from relationships to the content items holding the numerator and denominator values.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.9 |
Fetal Biometry Ratios |
||
|
1.9.1 |
HC/AC |
77% |
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1.9.2 |
FL/AC |
22 % |
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1.9.2.1 |
Normal Range Lower Limit |
20 % |
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1.9.2.2 |
Normal Range Upper Limit |
24 % |
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1.9.2.3 |
Normal Range Authority |
Hadlock, AJR 1983 |
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1.9.3 |
FL/BPD |
79 % |
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1.9.3.1 |
Normal Range Lower Limit |
71 % |
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1.9.3.2 |
Normal Range Upper Limit |
81 % |
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1.9.3.3 |
Normal Range Authority |
Hohler, Am J of Ob and Gyn 1981 |
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1.9.4 |
Cephalic Index |
82 % |
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1.9.4.1 |
Normal Range Lower Limit |
70 % |
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1.9.4.2 |
Normal Range Upper Limit |
86 % |
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1.9.4.3 |
Normal Range Authority |
Hadlock, AJR 1981 |
This example shows measurements and estimated gestational age.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.8 |
Fetal Biometry |
||
|
1.8.1 |
Biometry Group |
||
|
1.8.1.1 |
Biparietal Diameter |
5.5 cm |
|
|
1.8.1.2 |
Biparietal Diameter |
5.3 cm |
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1.8.1.3 |
Biparietal Diameter |
5.4 cm |
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1.8.1.3.1 |
Derivation |
Mean |
|
|
1.8.1.4 |
Gestational Age |
190 d |
|
|
1.8.1.4.1 |
Equation |
Jeanty, 1982 |
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|
1.8.1.4.2 |
5th Percentile Value of population |
131 d |
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1.8.1.4.3 |
95th Percentile Value of population |
173 d |
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|
1.8.2 |
Biometry Group |
||
|
1.8.2.1 |
Occipital-Frontal Diameter |
18.1 cm |
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1.8.3 |
Biometry Group |
||
|
1.8.3.1 |
Head Circumference |
34.3 cm |
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1.8.3.1.1 |
Derivation |
Estimated |
|
|
1.8.4 |
Biometry Group |
||
|
1.8.4.1 |
Abdominal Circumference |
34.9 cm |
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1.8.4.2 |
Abdominal Circumference |
34.3 cm |
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|
1.8.4.3 |
Abdominal Circumference |
34.3 cm |
|
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1.8.4.4 |
Abdominal Circumference |
34.5 cm |
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|
1.8.4.4.1 |
Derivation |
Mean |
|
|
1.8.4.5 |
Gestational Age |
190 d |
|
|
1.8.4.5.1 |
Equation |
Hadlock, 1984 |
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1.8.4.5.2 |
2 Sigma Lower Value of population |
184 d |
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1.8.4.5.3 |
2 Sigma Upper Value of population |
196 d |
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1.8.5 |
Biometry Group |
||
|
1.8.5.1 |
Femur Length |
4.5 cm |
|
|
1.8.5.n |
… |
This example shows measurements and with percentile ranking.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.8 |
Fetal Biometry |
||
|
1.8.1 |
Biometry Group |
||
|
1.8.1.1 |
Biparietal Diameter |
5.5 cm |
|
|
1.8.1.2 |
Biparietal Diameter |
5.3 cm |
|
|
1.8.1.3 |
Biparietal Diameter |
5.4 cm |
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1.8.1.3.1 |
Derivation |
Mean |
|
|
1.8.1.4 |
Growth Percentile Rank |
63 % |
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1.8.1.4.1 |
Equation |
BPD, Jeanty 1982 |
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|
1.8.2 |
Biometry Group |
||
|
1.8.2.n |
… |
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.6 |
Findings |
||
|
1.6.1 |
Finding Site |
Amniotic Sac |
|
|
1.6.2 |
Amniotic Fluid Index |
11 cm |
|
|
1.6.3 |
First Quadrant Diameter |
10 cm |
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1.6.4 |
Second Quadrant Diameter |
12 cm |
|
|
1.6.5 |
Third Quadrant Diameter |
11 cm |
|
|
1.6.6 |
Fourth Quadrant Diameter |
12 cm |
The content structure in the example below conforms to TID 5012 “Ovaries Section”. The example shows the volume derived from three perpendicular diameters.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.9 |
Findings |
||
|
1.9.1 |
Finding Site |
Ovary |
|
|
1.9.2 |
Ovary |
||
|
1.9.2.1 |
Left Ovary Volume |
6 cm3 |
|
|
1.9.2.2 |
Left Ovary Length |
3 cm |
|
|
1.9.2.3 |
Left Ovary Length |
3 cm |
|
|
1.9.2.4 |
Left Ovary Length |
3 cm |
|
|
1.9.2.4.1 |
Derivation |
Mean |
|
|
1.9.2.5 |
Left Ovary Width |
2 cm |
|
|
1.9.2.5.1 |
Derivation |
Mean |
|
|
1.9.2.6 |
Left Ovary Height |
2 cm |
|
|
1.9.2.6.1 |
Derivation |
Mean |
|
|
1.9.3 |
Ovary |
||
|
1.9.3.1 |
Right Ovary Volume |
7 cm3 |
|
|
1.9.3.2 |
… |
The content structure in the example below conforms to TID 5013 “Follicles Section”. It uses multiple measurements and derived averages for each of the perpendicular diameters.
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.8 |
Findings |
||
|
1.8.1 |
Finding Site |
Ovarian Follicle |
|
|
1.8.2 |
Laterality |
Right |
|
|
1.8.3 |
Number of follicles in right ovary |
2 |
|
|
1.8.4 |
Measurement Group |
||
|
1.8.4.1 |
Identifier |
#1 |
|
|
1.8.4.2 |
Volume |
3 cm3 |
|
|
1.8.4.3 |
Follicle Diameter |
15 mm |
|
|
1.8.4.4 |
Follicle Diameter |
13 mm |
|
|
1.8.4.5 |
Follicle Diameter |
14 mm |
|
|
1.8.4.5.1 |
Derivation |
Mean |
|
|
1.8.5 |
Measurement Group |
||
|
1.8.5.1 |
Identifier |
#2 |
|
|
1.8.5.2 |
Volume |
4 cm3 |
|
|
1.8.5.3 |
Follicle Diameter |
18 mm |
|
|
1.9 |
Findings |
||
|
1.9.1 |
Finding Site |
Ovarian Follicle |
|
|
1.9.2 |
Laterality |
Left |
|
|
1.9.3 |
Number of follicles in left ovary |
1 |
|
|
1.9.4 |
Follicle Measurement Group |
||
|
1.9.4.1 |
Identifier |
#1 |
|
|
1.9.4.2 |
Volume |
3 cm3 |
|
|
1.9.4.3 |
Follicle Diameter |
15 mm |
|
Nest |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID |
|---|---|---|---|
|
1 |
OB-GYN Ultrasound Procedure Report |
||
|
1.n |
…. |
||
|
1.9 |
Pelvis and Uterus |
||
|
1.9.1 |
Uterus |
||
|
1.9.1.1 |
Uterus Volume |
136 cm3 |
|
|
1.9.1.2 |
Uterus Length |
9.5 cm |
|
|
1.9.1.3 |
Uterus Width |
5.9 cm |
|
|
1.9.1.4 |
Uterus Height |
4.2 cm |
|
|
1.9.2 |
Endometrium Thickness |
4 mm |
|
|
1.9.3 |
Cervix Length |
5.3 cm |