Q.2 Breast Imaging Report Examples
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## Q.2 Breast Imaging Report Examples

The following are simple illustrations of encoding Mammography procedure based Breast Imaging Reports.

### Q.2.1 Example 1: Screening Mammogram With Negative Findings

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 only:

Example Q.2-1. Report Sample: Narrative Text Only

`Procedure reported`

`Film screen mammography, both breasts.`

`Reason for procedure`

`Screening`

`Findings`

`Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. 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`

Table Q.2-1. Breast Image Report Content for Example 1

Node | Code Meaning of Concept Name | Code Meaning or Example Value | TID/CID
--- | --- | --- | ---
1 | Breast Imaging Report |  | TID 4200
1.1 | Language of Content Item and Descendants | English | TID 1204
1.2 | Narrative Summary |  | TID 4202
1.2.1 | Procedure reported |  | TID 4202 CID 6052
1.2.1.1 | Procedure reported | Film screen mammography, both breasts. | TID 4202 CID 6053
1.2.2 | Reason for procedure |  | TID 4202 CID 6052
1.2.2.1 | Reason for procedure | Screening | TID 4202 CID 6053
1.2.3 | Findings |  | TID 4202 CID 6052
1.2.3.1 | Finding | Comparison was made to exam from 11/14/2001. The breasts are heterogeneously dense. This may lower the sensitivity of mammography. No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam. | TID 4202 CID 6053
1.2.4 | Impressions |  | TID 4202 CID 6052
1.2.4.1 | Impression | BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. | TID 4202 CID 6053

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