Lithuanian Breast Diagnostics Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Breast Diagnostics Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-breast/ and changes regularly. See the Directory of published versions

Questionnaire: Ultrasound Examination ESPBI Form (LT Breast)

Oficialus URL: https://hl7.lt/fhir/breast/Questionnaire/questionnaire-ultrasound-lt-breast Versija: 0.0.1
Mašiniškai apdorojamas pavadinimas: UltrasoundQuestionnaireLtBreast

Language: en

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. UltrasoundQuestionnaireLtBreast Questionnaire https://hl7.lt/fhir/breast/Questionnaire/questionnaire-ultrasound-lt-breast#0.0.1
... grp-exam-context Examination context 0..1 group Value Set:
.... exam-date Date of examination 0..1 dateTime Value Set:
.... exam-indication Indication for ultrasound (e.g. review for dense tissue, targeted for findings) 0..1 string Value Set:
... grp-right-breast Right breast 0..1 group Value Set:
.... right-parenchyma Structure of parenchyma 0..1 coding Value Set:
Options: 3 options
.... right-findings-present Findings present 0..1 coding Value Set:
Options: 2 options
.... right-finding-localization Finding localization (clock position) 0..1 string Value Set:
.... right-change-properties Change properties 0..1 text Value Set:
.... right-size-length Size – length (mm) 0..1 quantity Value Set:
.... right-size-width Size – width (mm) 0..1 quantity Value Set:
.... right-nature Nature of change 0..1 coding Value Set:
Options: 8 options
.... right-ducts Condition of ducts 0..1 coding Value Set:
Options: 2 options
.... right-lymph-changes Lymph node changes 0..1 coding Value Set:
Options: 2 options
.... right-lymph-localization Lymph node localization 0..1 coding Value Set:
Options: 2 options
.... right-lymph-level Lymph node level 0..1 coding Value Set:
Options: 3 options
.... right-lymph-count Number of altered lymph nodes 0..1 integer Value Set:
.... right-lymph-largest-size Size of largest lymph node (mm) 0..1 quantity Value Set:
... grp-left-breast Left breast 0..1 group Value Set:
.... left-parenchyma Structure of parenchyma 0..1 coding Value Set:
Options: 3 options
.... left-findings-present Findings present 0..1 coding Value Set:
Options: 2 options
.... left-finding-localization Finding localization (clock position) 0..1 string Value Set:
.... left-change-properties Change properties 0..1 text Value Set:
.... left-size-length Size – length (mm) 0..1 quantity Value Set:
.... left-size-width Size – width (mm) 0..1 quantity Value Set:
.... left-nature Nature of change 0..1 coding Value Set:
Options: 8 options
.... left-ducts Condition of ducts 0..1 coding Value Set:
Options: 2 options
.... left-lymph-changes Lymph node changes 0..1 coding Value Set:
Options: 2 options
.... left-lymph-localization Lymph node localization 0..1 coding Value Set:
Options: 2 options
.... left-lymph-level Lymph node level 0..1 coding Value Set:
Options: 3 options
.... left-lymph-count Number of altered lymph nodes 0..1 integer Value Set:
.... left-lymph-largest-size Size of largest lymph node (mm) 0..1 quantity Value Set:
.... notes Additional notes 0..1 text Value Set:
... grp-conclusion Conclusion 0..1 group Value Set:
.... birads-right BI-RADS – right breast 0..1 coding Value Set:
Options: 5 options
.... birads-left BI-RADS – left breast 0..1 coding Value Set:
Options: 5 options
.... recommendations Recommendations 0..* coding Value Set:
Options: 6 options

doco Documentation for this format

Options Sets

Answer options for right-parenchyma

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-fatty ("Homogeneous adipose tissue")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-fibroglandular ("Homogeneous fibroglandular")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-heterogeneous ("Heterogeneous")

Answer options for right-findings-present

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#yes ("Yes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#no ("No")

Answer options for right-nature

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-cyst ("Cyst")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-lymph-node ("Breast lymph node")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-fibroadenoma ("Fibroadenoma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-papilloma ("Papilloma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-lipoma ("Lipoma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-malignant ("Tumor (malignant)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-abscess ("Abscess")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-other ("Other (free text)")

Answer options for right-ducts

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ducts-normal ("Ducts not expanded")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ducts-expanded ("Ducts expanded")

Answer options for right-lymph-changes

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#yes ("Yes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#no ("No")

Answer options for right-lymph-localization

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#right ("Right")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#left ("Left")

Answer options for right-lymph-level

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n1 ("N1")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n2 ("N2")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n3 ("N3")

Answer options for left-parenchyma

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-fatty ("Homogeneous adipose tissue")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-fibroglandular ("Homogeneous fibroglandular")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#parenchyma-heterogeneous ("Heterogeneous")

Answer options for left-findings-present

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#yes ("Yes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#no ("No")

Answer options for left-nature

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-cyst ("Cyst")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-lymph-node ("Breast lymph node")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-fibroadenoma ("Fibroadenoma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-papilloma ("Papilloma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-lipoma ("Lipoma")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-malignant ("Tumor (malignant)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-abscess ("Abscess")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#nature-other ("Other (free text)")

Answer options for left-ducts

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ducts-normal ("Ducts not expanded")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ducts-expanded ("Ducts expanded")

Answer options for left-lymph-changes

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#yes ("Yes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#no ("No")

Answer options for left-lymph-localization

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#right ("Right")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#left ("Left")

Answer options for left-lymph-level

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n1 ("N1")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n2 ("N2")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ln-level-n3 ("N3")

Answer options for birads-right

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-1 ("BI-RADS 1 – No changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-2 ("BI-RADS 2 – Benign changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-3 ("BI-RADS 3 – Possibly benign changes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-4 ("BI-RADS 4 – Suspicious malignant finding")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-5 ("BI-RADS 5 – Highly probable malignant finding")

Answer options for birads-left

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-1 ("BI-RADS 1 – No changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-2 ("BI-RADS 2 – Benign changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-3 ("BI-RADS 3 – Possibly benign changes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-4 ("BI-RADS 4 – Suspicious malignant finding")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-5 ("BI-RADS 5 – Highly probable malignant finding")

Answer options for recommendations

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-mammographic-control ("Mammographic control")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-additional-mammography ("Additional mammography")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-ultrasound ("Ultrasound examination")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-breast-specialist ("Breast specialist consultation")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-biopsy-ultrasound ("Biopsy under ultrasound")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#rec-follow-up-6m ("Follow-up in 6 months")

Language: en

Examination context

  • linkId: grp-exam-context
  • Answers:

Date of examination

  • linkId: exam-date
  • Answers:

Indication for ultrasound (e.g. review for dense tissue, targeted for findings)

  • linkId: exam-indication
  • Answers:

Right breast

  • linkId: grp-right-breast
  • Answers:

Structure of parenchyma

Findings present

Finding localization (clock position)

  • linkId: right-finding-localization
  • Answers:

Change properties

  • linkId: right-change-properties
  • Answers:

Size – length (mm)

  • linkId: right-size-length
  • Answers:

Size – width (mm)

  • linkId: right-size-width
  • Answers:

Nature of change

Condition of ducts

Lymph node changes

Lymph node localization

Lymph node level

Number of altered lymph nodes

  • linkId: right-lymph-count
  • Answers:

Size of largest lymph node (mm)

  • linkId: right-lymph-largest-size
  • Answers:

Left breast

  • linkId: grp-left-breast
  • Answers:

Structure of parenchyma

Findings present

Finding localization (clock position)

  • linkId: left-finding-localization
  • Answers:

Change properties

  • linkId: left-change-properties
  • Answers:

Size – length (mm)

  • linkId: left-size-length
  • Answers:

Size – width (mm)

  • linkId: left-size-width
  • Answers:

Nature of change

Condition of ducts

Lymph node changes

Lymph node localization

Lymph node level

Number of altered lymph nodes

  • linkId: left-lymph-count
  • Answers:

Size of largest lymph node (mm)

  • linkId: left-lymph-largest-size
  • Answers:

Notes

  • linkId: grp-notes
  • Answers:

Additional notes

  • linkId: notes
  • Answers:

Conclusion

  • linkId: grp-conclusion
  • Answers:

BI-RADS – right breast

BI-RADS – left breast

Recommendations

Language: en

LinkIDDescription & Constraintsdoco
.. grp-exam-context Value Set:
... exam-date Value Set:
... exam-indication Value Set:
.. grp-right-breast Value Set:
... right-parenchyma Value Set:
Options: 3 options
... right-findings-present Value Set:
Options: 2 options
... right-finding-localization Value Set:
... right-change-properties Value Set:
... right-size-length Value Set:
... right-size-width Value Set:
... right-nature Value Set:
Options: 8 options
... right-ducts Value Set:
Options: 2 options
... right-lymph-changes Value Set:
Options: 2 options
... right-lymph-localization Value Set:
Options: 2 options
... right-lymph-level Value Set:
Options: 3 options
... right-lymph-count Value Set:
... right-lymph-largest-size Value Set:
.. grp-left-breast Value Set:
... left-parenchyma Value Set:
Options: 3 options
... left-findings-present Value Set:
Options: 2 options
... left-finding-localization Value Set:
... left-change-properties Value Set:
... left-size-length Value Set:
... left-size-width Value Set:
... left-nature Value Set:
Options: 8 options
... left-ducts Value Set:
Options: 2 options
... left-lymph-changes Value Set:
Options: 2 options
... left-lymph-localization Value Set:
Options: 2 options
... left-lymph-level Value Set:
Options: 3 options
... left-lymph-count Value Set:
... left-lymph-largest-size Value Set:
.. grp-notes Value Set:
... notes Value Set:
.. grp-conclusion Value Set:
... birads-right Value Set:
Options: 5 options
... birads-left Value Set:
Options: 5 options
... recommendations Value Set:
Options: 6 options

doco Documentation for this format

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