Breast Radiology Reporting - 1st for comment ballot

This page is part of the Breast Radiology Report (v0.1.0: Comment Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Primary extensions defined as part of this Implementation Guide

Name Definition
AnatomicalOrientation

AnatomicalOrientation of the body location, if needed to distinguish from a similar location in another orientation. The orientation element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
    1. Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
    2. Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR’s stand-alone BodySite (aka BodyStructure in r4) which ‘is not … intended for describing the type of anatomical location but rather a specific body site on a specific patient’ (FHIR 3.5).

BreastExamTechnique

Technique used during breast examination.

Code

The main type identifier for a lab, procedure, condition, etc., usually drawn from a controlled vocabulary.

LandmarkLocation

The body location of the landmark, specified by a location code and optional laterality and orientation.

LandmarkToBodyLocationDirection

The direction from the landmark to the body location of interest, given as a clockface direction or anatomical direction.

LandmarkToBodyLocationDistance

How far the body location of interest is from the given landmark.

LandmarkType

The type of feature that constitutes the landmark, particularly if the landmark is an acquired body structure or physical object.

Laterality

Body side of the body location, if needed to distinguish from a similar location on the other side of the body.

The laterality element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
    1. Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
    2. Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR’s stand-alone BodySite (aka BodyStructure in r4) which ‘is not … intended for describing the type of anatomical location but rather a specific body site on a specific patient’ (FHIR 3.5).

RelationToLandmark

The relationship between a landmark that helps determine a body location and the body location itself. The location relative to a landmark is specified by:

  • Specifying the location and type of landmark using a body site code and optional laterality/orientation,
  • Specifying the direction from the landmark to the body location, and
  • Specifying the distance from the landmark to the body location.

The RelationToLandmark element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
    1. Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
    2. Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR’s stand-alone BodySite (aka BodyStructure in r4) which ‘is not … intended for describing the type of anatomical location but rather a specific body site on a specific patient’ (FHIR 3.5).

ResultComposition

Reference to the document containing detailed information about the breast radiology report, including assocated sections

SummaryBiRadCode

BiRd code that summarizes a set of BiRad codes in a the document. Generally the most concerning/important BiRad code in the document.