A screening mammography case, i.e., there are typically four films and no suspicious abnormalities. The result is a negative mammogram with basic reporting. This example illustrates a report encoded as narrative text with minimal supplementary data, and follows BI-RADS® and MQSA:
Example Q.2-2. Report Sample: Narrative Text with Minimal Supplementary Data
Procedure reported
Film screen mammography, both breasts.
Reason for procedure
Screening
Comparison to previous exams
Comparison was made to exam from 11/14/2001.
Breast composition
The breasts are heterogeneously dense. This may lower the sensitivity of mammography.
Findings
No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.
Impressions
BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.
Overall Assessment
Negative
Table Q.2-2. Breast Imaging Report Content for Example 2
|
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, both breasts. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
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 |
Breast composition |
||
|
1.2.4.1 |
Breast composition |
The breasts are heterogeneously dense. This may lower the sensitivity of mammography. |
|
|
1.2.5 |
Findings |
||
|
1.2.5.1 |
Finding |
No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam. |
|
|
1.2.6 |
Impressions |
||
|
1.2.6.1 |
Impression |
BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. |
|
|
1.2.7 |
Overall Assessment |
||
|
1.2.7.1 |
Overall Assessment |
Negative |
|
|
1.3 |
Supplementary Data |
||
|
1.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.1.1 |
Laterality |
Both breasts |
|
|
1.3.1.2 |
Reason for procedure |
Screening |
|
|
1.3.2 |
Breast composition |
||
|
1.3.2.1 |
Breast composition |
Heterogeneously dense |
|
|
1.3.2.1.1 |
Laterality |
Both breasts |
|
|
1.3.3 |
Overall Assessment |
||
|
1.3.3.1 |
Assessment Category |
1 - Negative |
|
|
1.3.3.2 |
Recommended Follow-up |
Normal interval follow-up |