Following a screening mammogram, the patient was asked to return for additional imaging and an ultrasound on the breast, for further evaluation of a mammographic mass. This example demonstrates a report on multiple breast imaging procedures. This report provides the narrative text with some supplementary data.
Example Q.2-4. Report Sample: Multiple Procedures, Narrative Text with Some Supplementary Data
Procedure reported
Film screen mammography, left breast; Ultrasound procedure, left breast.
Reason for procedure
Additional evaluation requested at current screening.
Comparison to previous exams
Comparison was made to exam from 11/14/2001.
Findings
Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.
Findings
Ultrasound demonstrates a simple cyst.
Impressions
BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.
Overall Assessment
Benign
Table Q.2-4. Breast Imaging Report Content for Example 4
|
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; Ultrasound procedure, left breast. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Additional evaluation requested at current screening. |
|
|
1.2.3 |
Comparison to previous exams |
||
|
1.2.3.1 |
Comparison to previous exams |
Comparison was made to exam from 11/14/2001. |
|
|
1.2.4 |
Findings |
||
|
1.2.4.1 |
Finding |
Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant. |
|
|
1.2.5 |
Findings |
||
|
1.2.5.1 |
Finding |
Ultrasound demonstrates a simple cyst. |
|
|
1.2.6 |
Impressions |
||
|
1.2.6.1 |
Impression |
BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months. |
|
|
1.2.7 |
Overall Assessment |
||
|
1.2.7.1 |
Overall Assessment |
Benign |
|
|
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 |
Additional evaluation requested at current screening |
|
|
1.3.2 |
Procedure reported |
Ultrasound procedure |
|
|
1.3.2.1 |
Laterality |
Left breast |
|
|
1.3.2.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.3 |
Findings |
||
|
1.3.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.3.1.1 |
Laterality |
Left breast |
|
|
1.3.3.1.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.3.2 |
Finding |
Mammographic breast mass |
|
|
1.3.3.2.1 |
Quadrant location |
Upper outer quadrant of breast |
|
|
1.3.3.2.2 |
Diameter |
7 mm |
|
|
1.3.3.2.3 |
Shape |
Lobular |
|
|
1.3.3.2.4 |
Margins |
Obscured lesion |
|
|
1.3.4 |
Findings |
||
|
1.3.4.1 |
Procedure reported |
Ultrasound procedure |
|
|
1.3.4.1.1 |
Laterality |
Left breast |
|
|
1.3.4.1.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.4.2 |
Finding |
Simple cyst of breast |
|
|
1.3.5 |
Overall Assessment |
||
|
1.3.5.1 |
Assessment Category |
2 - Benign Finding |