A diagnostic mammogram was prompted by a clinical finding. The result is a probably benign finding with a short interval follow-up of the left breast. This report provides the narrative text with more extensive supplementary data.
Example Q.2-3. Report Sample: Narrative Text with More Extensive Supplementary Data
Procedure reported
Film screen mammography, left breast.
Reason for procedure
Non-bloody discharge left breast.
Breast composition
The breast is almost entirely fat.
Findings
Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.
Impressions
BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.
Table Q.2-3. Breast Imaging Report Content for Example 3
|
Node |
Code Meaning of Concept Name |
Code Meaning or Example Value |
TID/CID |
|---|---|---|---|
|
1 |
Breast Imaging Report |
||
|
1.1 |
Language of Content Item and Descendants |
English |
|
|
1.2 |
Narrative Summary |
||
|
1.2.1 |
Procedure reported |
||
|
1.2.1.1 |
Procedure reported |
Film screen mammography, left breast. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Non-bloody discharge left breast. |
|
|
1.2.3 |
Breast composition |
||
|
1.2.3.1 |
Breast composition |
The breast is almost entirely fat. |
|
|
1.2.4 |
Findings |
||
|
1.2.4.1 |
Finding |
Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o'clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam. |
|
|
1.2.5 |
Impressions |
||
|
1.2.5.1 |
Impression |
BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months. |
|
|
1.3 |
Supplementary Data |
||
|
1.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.1.1 |
Laterality |
Left breast |
|
|
1.3.1.2 |
Reason for procedure |
Clinical Finding |
|
|
1.3.1.2.1 |
Clinical Finding |
Non-bloody discharge |
|
|
1.3.1.2.1.1 |
Laterality |
Left breast |
|
|
1.3.2 |
Breast composition |
||
|
1.3.2.1 |
Breast composition |
Almost entirely fat |
|
|
1.3.2.1.1 |
Laterality |
Left breast |
|
|
1.3.3 |
Findings |
||
|
1.3.3.1 |
Finding |
Calcification of breast |
|
|
1.3.3.1.1 |
Assessment Category |
3 - Probably Benign Finding - short interval follow-up |
|
|
1.3.3.1.2 |
Recommended Follow-up |
Follow-up at short interval (1-11 months) |
|
|
1.3.3.1.2.1 |
Laterality |
Left breast |
|
|
1.3.3.1.2.2 |
Recommended Follow-up Interval |
6 months |
|
|
1.3.3.1.3 |
Clockface or region |
1 o'clock position |
|
|
1.3.3.1.4 |
Quadrant location |
Upper outer quadrant of breast |
|
|
1.3.3.1.5 |
Depth |
Anterior |
|
|
1.3.3.1.6 |
Calcification Type |
Heterogeneous calcification |
|
|
1.3.3.1.7 |
Calcification Distribution |
Regional calcification distribution |
|
|
1.3.3.1.8 |
Change since last mammogram |
Increase in number of calcifications |