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National Interim Standard Descriptions for Clinical Imaging

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National Interim Standard Descriptions for Clinical Imaging National Interim Standard Descriptions for Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles Programme NPFIT Sub-Prog / Terminology Project NPFIT-NCR-DES-1076.06 Prog. Director Paul Jones Owner Ian Arrowsmith Version 3.2 Author Ian Arrowsmith Version Date 18/09/2008 Status Final National Interim Standard Descriptions for Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles © Crown Copyright 2004 Page 1 of 42 National Interim Standard Descriptions for NPFIT-NCR-DES-1076.01 V3.2 Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles 18th September 2008 Amendment History: Version Date Amendment History 0.1 01/01/2006 First draft for comment 0.2 18/01/2006 Revised after internal comment 0.3 27/02/2006 Revised after consideration of new term submissions 0.4 24/03/2006 Revised after further evolution of editorial principles 0.5 12/07/2006 Further elaboration of editorial policy 0.6 14/08/2006 Inclusion of modality definitions and further clarifications 0.7 15/09/2006 Final refinement prior to formal review 0.8 22/09/2006 Inclusion of information on legacy, meaningful code structure 0.9 29/12/2006 Further development of interventional radiology section 1.0 26/01/2007 Final revisions prior to Jan 2007 release 1.1 14/09/2007 Incorporation of new principles and more information on SNOMED representation 1.2 05/09/2007 Amendment after initial review 2.0 22/10/07 Final approved version for October 2007 release 2.1 05/08/2008 First re-draft for April 2008 release 2.2 13/03/2008 Redraft after internal comment for management group review 3.0 01/04/2008 Final approved version for April 2008 release 3.1 22/08/2008 First re-draft for October 2008 release 3.2 18/9/08 Removed reference to z codes Forecast Changes: Anticipated Change When Will be updated as necessary upon each release of the data September 2008 Reviewers: This document must be reviewed by the following. Indicate any delegation for sign off. Name Signature Title / Responsibility Date Version Yonsheng Gao Clinical Terminology Specialist Clinical Imaging Various Management Group (CIMG) Rhidian Bramley Consultant Radiologist, RCR representative on CIMG Maria Clinical Terminology Braithwaite Specialist Deborah Clinical Terminology Horwood Specialist Approvals: This document requires the following approvals: Name Signature Title / Responsibility Date Version Ken Lunn Head of Data Standards and Products and Comms and Messaging Paul Jones Chief Technical Officer Distribution: <Document text>. © Crown Copyright 2004 Page 2 of 42 National Interim Standard Descriptions for NPFIT-NCR-DES-1076.01 V3.2 Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles 18th September 2008 Document Status: This is a controlled document. This document version is only valid at the time it is retrieved from controlled filestore, after which a new approved version will replace it. On receipt of a new issue, please destroy all previous issues (unless a specified earlier issue is baselined for use throughout the programme). Related Documents: These documents will provide additional information. Ref no Doc Reference Number Title Version 1 NPFIT-NPO-GEN-IP-0067 Glossary of Terms Consolidated.doc <enter latest> Glossary of Terms: List any new terms created in this document. Mail the NPO Quality Manager to have these included in the master glossary above [1]. Term Acronym Definition © Crown Copyright 2004 Page 3 of 42 National Interim Standard Descriptions for NPFIT-NCR-DES-1076.01 V3.2 Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles 18th September 2008 Contents 1 Purpose .............................................................................................................................. 6 2 Background ........................................................................................................................ 6 2.1 The NHS Care Records Service ................................................................................... 6 2.2 SNOMED Clinical Terms Clinical Imaging Procedures subset .................................... 6 2.3 National Programme for IT and the NHS PACS Programme ....................................... 6 2.4 Interim coding scheme for existing PACS and RIS systems ........................................ 6 2.4.1 Background .......................................................................................................... 7 2.4.2 Proposal ............................................................................................................... 7 3 Principles underlying the composition of the interim descriptions ...................................... 8 3.1 Modality (method) ......................................................................................................... 8 3.1.1 Modality-specific guidance ................................................................................... 9 3.2 Functional domain-specific principles ......................................................................... 13 3.2.1 Breast imaging ................................................................................................... 13 3.2.2 Interventional Radiology .................................................................................... 14 3.2.3 Dental Radiography ........................................................................................... 16 3.2.4 Medical photography .......................................................................................... 16 3.3 Body site ..................................................................................................................... 16 3.4 Laterality ..................................................................................................................... 17 3.5 Associated Procedure/Disorder .................................................................................. 17 3.6 Operative procedures ................................................................................................. 18 3.7 Contrast ...................................................................................................................... 18 3.8 Administrative aspects ................................................................................................ 19 3.8.1 Location.............................................................................................................. 19 3.8.2 Report ................................................................................................................ 19 3.8.3 Procedure status ................................................................................................ 19 3.8.4 Visit information ................................................................................................. 20 3.8.5 Performer ........................................................................................................... 20 3.9 View/Projection/Technique adjustments .................................................................... 20 3.10 Route/method of Administration ............................................................................. 21 3.11 Proprietary descriptions ......................................................................................... 21 3.12 Research activities ................................................................................................. 22 3.13 Additional style guidance ....................................................................................... 22 3.13.1 Term length ........................................................................................................ 22 3.13.2 Plurality .............................................................................................................. 22 3.13.3 Prepositions and conjunctions ........................................................................... 22 3.13.4 Exclusions and catch-all categories ................................................................... 22 3.13.5 Punctuation (parentheses, colons, full-stops, commas) .................................... 23 3.13.6 Capitalisation ..................................................................................................... 23 3.13.7 Suffices .............................................................................................................. 23 3.13.8 Combined procedures ........................................................................................ 23 3.14 Acronyms and abbreviations in the DI interim procedure list ................................. 24 4 Proposed technical representation ................................................................................... 25 4.1 SNOMED CT .............................................................................................................. 25 4.2 Basic Elements of SNOMED CT ................................................................................ 25 4.3 Constraints preventing use of SNOMED CT subset and concepts ............................ 26 4.4 SNOMED CT for Interim list ....................................................................................... 26 4.4.1 Imaging procedure modelling ............................................................................ 26 4.4.4 Requirement for additional concepts ................................................................. 29 4.4.5 Guidelines for addition of concepts ...................................................................
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