Lithuanian Breast Diagnostics Implementation Guide
0.0.1 - ci-build
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
Dabartiniam puslapiui nėra vertimo puslapio, todėl jis pateiktas numatytąja kalba
Turinys:
Šiame puslapyje pateikiamas FHIR artefaktų, apibrėžtų šiame diegimo vadove, sąrašas.
Jie apibrėžia formas, kurias naudoja sistemos, atitinkančios šį įgyvendinimo vadovą, duomenims rinkti ar pateikti galutiniams vartotojams.
| Questionnaire: Mammogram ESPBI Form (LT Breast) |
Structured data-capture form for mammogram reporting based on ADP Table 7.1. |
| Questionnaire: Tomosynthesis ESPBI Form (LT Breast) |
Structured data-capture form for breast tomosynthesis reporting based on ADP Table 7.2. |
Jie apibrėžia FHIR resursų apribojimus sistemoms, atitinkančioms šį įgyvendinimo vadovą.
| BI-RADS Assessment |
Final radiological diagnostic conclusion according to BI-RADS classification. |
| Breast Biopsy Procedure (LT Breast) |
Breast biopsy procedure profile for the breast cancer prevention program, covering ultrasound-guided and X-ray-guided biopsy types. |
| Breast Body Structure |
BodyStructure profile representing breast structures including laterality and quadrants. |
| Breast Composition (LT Breast) |
Breast-specific imaging composition extending the base imaging composition with breast-specific constraints on findings, impression, and history sections. Designed for use in the Lithuanian breast cancer prevention programme. |
| Breast Diagnostic Report (LT Breast) |
Overall breast diagnostic report covering the entire breast cancer diagnostic pathway. Wraps a BreastCompositionLtBreast and aggregates structured results including BI-RADS assessments, mammographic findings, ultrasound findings, gland density, and nipple observations. |
| Breast Duct Condition (LT Breast) |
Breast duct condition observation as assessed by ultrasound, recorded per breast side. |
| Breast Examination Order |
A profile of ServiceRequest used to capture a clinical recommendation (e.g., follow-up ultrasound, surgical referral). |
| Breast Gland Density |
Breast gland density observation according to ACR BI-RADS classification. |
| Breast History Assessment |
Breast history assessment according to the patient saying. |
| Breast Nipple Inversion |
Observation representing nipple inversion assessment in a patient summary. |
| Breast Observation Finding |
Breast observation findings. |
| Breast Parenchyma Structure (LT Breast) |
Ultrasound breast parenchyma structure observation per breast side. |
| Breast Ultrasound Findings |
A radiology observation representing one specific ultrasound lesion with localization, dimensions, and characteristics. |
| Mammographic Examination Findings |
Observation representing mammographic breast changes using BodyStructure. |
| Mammography Diagnostic Report (LT Breast) |
A Diagnostic Report for Mammography imaging studies. Aggregates BI-RADS assessments, mammographic findings, ultrasound findings, and general breast observations. |
| Tomosynthesis Examination Finding (LT Breast) |
Observation representing tomosynthesis breast findings including finding type, size, cross-section localization in CC and MLO projections, and finding evolution. |
Jie apibrėžia kodų rinkinius, naudojamus sistemų, atitinkančių šį įgyvendinimo vadovą.
| BI-RADS Category |
Categories of Breast Imaging Reporting and Data System. |
| Breast Assessment Services and Procedures |
This ValueSet includes all clinical services and procedures related to the assessment and diagnostic evaluation of the breast, such as imaging, biopsy, and specialist referrals. |
| Breast Biopsy Procedure Type |
Types of breast biopsy procedures used in the breast cancer prevention program. |
| Breast Body Site |
Entire breast and left/right breasts. |
| Breast Clock Position |
Clock positions (1-12 o'clock) for localizing breast findings. |
| Breast Duct Condition |
Breast duct condition as assessed by ultrasound examination. |
| Breast Finding |
SNOMED CT finding representing findings on the breast. |
| Breast Gland Density ACR |
ACR (BI-RADS) glandular density assessment. |
| Breast History Situations |
A value set of SNOMED CT situations representing various types of breast history. |
| Breast Nipple Appearance Finding |
SNOMED CT finding representing findings of the breast nipple appearance. |
| Breast Parenchyma Structure |
Ultrasound breast parenchyma structure classification. |
| Breast Quadrants |
Quadrants of the breast. |
| Finding Evolution |
Evolution of findings during the mammographic procedure. |
| Lymph Node Level |
Regional lymph node involvement level (N1, N2, N3) for breast diagnostics. |
| Mammographic Finding |
Findings during the mammographic procedure. |
| Ultrasound Lesion Finding |
Lesions findings identified during breast ultrasound. |
| WHO Breast Tumor Classification |
Breast tumor pathological diagnosis codes according to the WHO Classification of Tumours, 5th edition. Used for pathological histological examination conclusion/diagnosis in the breast cancer prevention program. |
Jie apibrėžia naujas kodų sistemas, naudojamas sistemų, atitinkančių šį įgyvendinimo vadovą.
| Breast questionnaire answer options (illustrative) |
Illustrative codes for Questionnaire answer options used in breast ESPBI-style forms. Register or replace with national coded values in production. |
| SNOMED Breast Extension |
Extension codes for breast diagnostics concepts not yet available in SNOMED CT. These codes are intended to be replaced by official SNOMED CT codes when they become available. |
Tai yra pavyzdiniai egzemplioriai, kurie parodo, kaip gali atrodyti duomenys, sukurti ir sunaudoti sistemų, atitinkančių šį įgyvendinimo vadovą.
| BodyStructure: Bilateral Upper Inner Quadrant (example) |
Bilateral upper inner quadrant body structure. |
| BodyStructure: Left Breast Upper Outer Quadrant (example) |
Left breast upper outer quadrant for mammographic localization. |
| BodyStructure: Left Breast – Upper Outer Quadrant (example) |
Left breast upper outer quadrant body structure for anatomical localization. |
| BodyStructure: Right Breast Lower Inner Quadrant (example) |
Right breast lower inner quadrant for mammographic localization. |
| BodyStructure: Right Breast – Upper Inner Quadrant (example) |
Right breast upper inner quadrant body structure. |
| CarePlan: Breast Follow-up (example) |
Follow-up care plan for breast screening with BI-RADS-based recommendations. |
| Composition: Breast Diagnostic Process (example) |
Imaging composition summarizing the breast cancer ADP diagnostic process with all required sections. |
| DiagnosticReport: Breast Diagnostic Report (example) |
Example of a complete breast diagnostic report aggregating imaging composition, BI-RADS assessment, gland density, and mammographic findings. |
| DiagnosticReport: Breast Imaging (example) |
Placeholder DiagnosticReport referenced by the breast imaging composition. |
| Encounter: Breast Imaging Acquisition Step 2 (example) | |
| Encounter: First Visit (example) |
First outpatient encounter for breast imaging screening. |
| Encounter: Palpation (example) |
The specific encounter where the breast history and palpation were performed. |
| ImagingStudy: Mammography (example) |
Mammography imaging study with bilateral breast series. |
| ImagingStudy: Previous Mammography (example) |
Prior mammography study used for comparison in the current evaluation. |
| Observation: Asymmetric Tissue – Bilateral UIQ (example) |
Focal asymmetric breast tissue finding increasing bilaterally in upper inner quadrants. |
| Observation: BI-RADS 1 – Negative (example) |
BI-RADS category 1 (Negative) assessment – no abnormality detected. |
| Observation: BI-RADS 4 – Suspicious Abnormality (example) |
BI-RADS category 4 (Suspicious Abnormality) – biopsy should be considered. |
| Observation: Breast Density – Fatty (example) |
Mammography shows predominantly fatty breast density. |
| Observation: Breast Injury History (example) | |
| Observation: Breast Lesion – Right Cyst (example) |
Ultrasound finding of a cyst in the right breast at 10 o'clock. |
| Observation: Breast Nipple Inversion (example) |
An example instance of a breast nipple inversion observation. |
| Observation: Breast Scar (example) |
An example instance of a breast scar observation. |
| Observation: Breast Skin Formation (example) |
Observation of a skin mass on the breast surface. |
| Observation: Breast Surgery History (example) | |
| Observation: Lesion – Left Fibroadenoma (example) |
Ultrasound finding of a fibroadenoma in the left breast at 3 o'clock. |
| Observation: Lesion – Right Malignant Tumor (example) |
Ultrasound finding of a malignant tumor in the right breast at 6 o'clock. |
| Observation: Mammographic Calcification – Right LIQ (example) |
Mammographic calcification finding in the right lower inner quadrant, unchanged. |
| Observation: Mammographic Mass – Left UOQ (12 mm) (example) |
Mammographic finding of a new 12 mm mass in the left upper outer quadrant. |
| Observation: No Breast Disease History (example) | |
| Observation: No Mammographic Architectural Distortion (example) |
Negative mammographic finding – no architectural distortion detected. |
| Observation: Radiation Dose (example) |
Radiation dose of 2.5 mGy recorded during the mammography procedure. |
| Organization: Breast Clinic (example) |
Example healthcare organization providing breast diagnostic services. |
| Patient: Janette Petrauskaite (example) |
An example Patient conforming to the Lithuanian Base Profile. |
| Practitioner: Diagnostic Radiologist (example) |
Diagnostic radiologist evaluating mammography studies. |
| Practitioner: Triage Nurse (example) |
Triage nurse practitioner involved in breast screening workflow. |
| PractitionerRole: Radiologist (example) |
Radiologist role linked to the breast diagnostics organization. |
| Procedure: Breast Palpation (example) |
Clinical breast palpation performed during the initial outpatient visit. |
| Procedure: Mammography (example) |
Bilateral digital mammography procedure during imaging acquisition. |
| Procedure: Palpation – Mass Finding (example) |
Breast palpation procedure revealing a palpable mass. |
| Questionnaire: Biopsy ESPBI Form (LT Breast) |
ESPBI-style form for breast biopsy data capture, based on ADP Table 7.4. |
| Questionnaire: Pathological Histological Examination ESPBI Form (LT Breast) |
ADP Table 7.5 — Pathological histological examination questionnaire for Lithuanian breast diagnostics ESPBI-style forms. |
| Questionnaire: Ultrasound Examination ESPBI Form (LT Breast) |
ESPBI-style form for breast ultrasound examination data capture, based on ADP Table 7.3. |
| QuestionnaireResponse: Biopsy – Right Breast Mass (example) |
Completed biopsy ESPBI form: US-guided core biopsy of a 15 mm mass in the right breast at 10 o'clock, BI-RADS 4, 2 sample containers. |
| QuestionnaireResponse: Mammogram ESPBI (example) |
Screening mammogram example – ACR B density, no findings, BI-RADS 1. |
| QuestionnaireResponse: Pathological Histological Examination (example) |
Example response for pathological histological examination — invasive ductal carcinoma, core needle biopsy, ER+/PR+/HER2 borderline. |
| QuestionnaireResponse: Tomosynthesis ESPBI (example) |
Tomosynthesis follow-up for BI-RADS 0 – mass found in right breast UOQ, BI-RADS 4. |
| QuestionnaireResponse: Ultrasound – Cyst Left Breast (example) |
Completed ultrasound ESPBI form: targeted examination revealing a simple cyst in the left breast at 2 o'clock, 8 x 6 mm, BI-RADS 2. |
| ServiceRequest: BI-RADS Category 4 Referral (example) |
A ServiceRequest instance recommending a referral to a breast surgeon due to a Category 4 (suspicious) BI-RADS finding. |
| ServiceRequest: Breast Screening (example) |
An example of a ServiceRequest for breast cancer screening. |