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 local value sets used in this Implementation Guide

Name Definition
AbnormalityDensityVS

Visually estimated content of fibroglandular-density tissue within the breast

AbnormalityTypeVS

Abnormality Type value

AnatomicalDirectionVS

Terms that specify anatomical direction.

AnatomicalOrientationVS

Terms that specify anatomical orientation. The orientation value set 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).

AsymmetryTypesVS

Currently many studies utilize cortical thickening and hilum absence as criteria for definition of the risk for metastasis(11,12-16). … Metastatic deposits accumulate in the lymph node peripheral area, causing enlargement of the cortex, usually focal (at early stages), or uniform.

BiRadCodeVS

Bi-Rad code value

BreastAbnormalityCodesVS

Breast Abnormality Codes

BreastDensityVS

Breast density values

BreastDepthVS

Breast Depth

BreastDirectionVS

The relative direction of an object described using the analogy of a 12-hour clock to describe angles and directions. One imagines a clock face lying either upright or flat in front of oneself, and identifies the twelve hour markings with the directions in which they point.

CalcificationTypeVS

Calcification Type

ChangeVS

Change value

CystTypesVS

Cyst Types

DiagnosticTechniqueVS

Breast exam diagnostic technique

ForeignBodyVS

Foreign Body

HilumVS

Hilum

LandmarkTypeVS

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

LymphNodeQualifiersVS

Lymph Node Qualifiers

MarginVS

When breast cancer is surgically removed (during a surgical biopsy, lumpectomy or mastectomy), a rim of normal tissue surrounding the tumor is also removed. This rim is called a margin. Margins help show whether or not all of the tumor was removed.

MassTypesVS

Mass Types

NodeTypesVS

Node Types

ShapeVS

Shape

UnitsOfLengthVS

Units of measure related to length or distance.

VascularityVS

Vascularity

WallVS

Wall

Primary external value sets used in this Implementation Guide

Name Definition
CommonLanguages

This value set includes common codes from BCP-47 (http://tools.ietf.org/html/bcp47)

CompositionAttestationMode

The way in which a person authenticated a composition.

CompositionStatus

The workflow/clinical status of the composition.

DataAbsentReason

Used to specify why the normally expected content of the data element is missing.

DiagnosticReportStatus

The status of the diagnostic report.

DocumentClassValueSet

This is the code specifying the high-level kind of document (e.g. Prescription, Discharge Summary, Report, etc.). Note: Class code for documents comes from LOINC, and is based upon one of the following:The type of service described by the document. It is described at a very high level in Section 7.3 of the LOINC Manual. The type study performed. It was determined by identifying modalities for study reports. The section of the chart where the document is placed. It was determined from the SETs created for Claims Attachment requests.

DocumentRelationshipType

The type of relationship between documents.

DocumentSectionCodes

Document section codes (LOINC codes used in CCDA sections).

FHIRDocumentTypeCodes

FHIR Document Codes - all LOINC codes where scale type = ‘DOC’.

LOINCCodes

This value set includes all LOINC codes

Laterality

Laterality: SNOMED-CT concepts for ‘left’, ‘right’, and ‘bilateral’

ListEmptyReasons

General reasons for a list to be empty. Reasons are either related to a summary list (i.e. problem or medication list) or to a workflow related list (i.e. consultation list).

ListMode

The processing mode that applies to this list.

ListOrderCodes

Base values for the order of the items in a list resource.

ObservationCategoryCodes

Observation Category codes.

ObservationInterpretationCodes

A categorical assessment, providing a rough qualitative interpretation of the observation value, such as “normal”/ “abnormal”,”low” / “high”, “better” / “worse”, “susceptible” / “resistant”, “expected”/ “not expected”. The value set is intended to be for ANY use where coded representation of an interpretation is needed.

Notes:

This is being communicated in v2.x in OBX-8 (Observation Interpretation), in v3 in ObservationInterpretation (CWE) in R1 (Representative Realm) and in FHIR in Observation.interpretation. Historically these values come from the laboratory domain, and these codes are extensively used. The value set binding is extensible, so codes outside the value set that are needed for interpretation concepts (i.e. particular meanings) that are not included in the value set can be used, and these new codes may also be added to the value set and published in a future version.

ObservationMethods

Observation Method codes from SNOMED CT where concept is-a 272394005 (Technique (qualifier value)) or is-a 129264002 (Action (qualifier value)) or is-a 386053000 (Evaluation procedure(procedure))

ObservationReferenceRangeAppliesToCodes

This value set defines a set of codes that can be used to indicate the particular target population the reference range applies to.

ObservationReferenceRangeMeaningCodes

This value set defines a set of codes that can be used to indicate the meaning/use of a reference range for a particular target population.

ObservationStatus

Codes providing the status of an observation.

QuantityComparator

How the Quantity should be understood and represented.

SNOMEDCTBodyStructures

This value set includes all codes from SNOMED CT where concept is-a 442083009 (Anatomical or acquired body site (body structure)).

SNOMEDCTClinicalFindings

This value set includes all the “Clinical finding” SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).

USCoreDiagnosticReportCategory

The US Core Diagnostic Report Category Value Set is a ‘starter set’ of categories supported for fetching and Diagnostic Reports and notes.

USCoreDiagnosticreportReportAndNoteCodes

This value set currently contains all of LOINC. The codes selected should represent discrete and narrative diagnostic observations and reports

http://terminology.hl7.org/ValueSet/v3-ActCode
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification