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The Radiology Information Solution 106740585 CRIS Fetal Anomaly Module REPORTING AND SONOGRAPHER MODE is recommended for users who are responsible for typing and printing Obstetric reports. CRIS will automatically display / highlight the most appropriate screens and buttons. When printing Fetal Anomaly Reports, only identified abnormalities will be printed with details whilst any normal values will be grouped together – i.e. No abnormalities were seen in the following: head, lips and nostrils, lens, spine, arms, hands, feet, heart etc. ANOMALY SCAN (NW) To select from the options in each drop down list use [F4] or double click. Select the value you want and [Enter] or double click. UTERUS REPORT Maternal Blood Type Anti- D given A / AB / B / O +ve / -ve Tick to select To type additional comments left click beneath and begin typing. ANOMALY SCAN (NW) Fetal Identifier Enter as appropriate More Than One Fetal heartbeat Not Present Present TA + TV Scan type Trans Abdominal Trans Vaginal Amniocentesis New Anomaly Booking Indication Bleeding See Comments CVS Diabetic Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 1 of 21 Dating Foetal Study Growth Medical Disorder Prev Fetal Abnom Poor Obs History Pain Prev Obs History Reassurance Rescan Anomaly Transfer Booker Twins Viability Anterior Fundal Placenta Left Lateral Posterior Right Lateral Abutting OS Clear of OS Covering OS. Enter in mm. Position Low, clear of OS Low Lying Overlying OS. Enter in mm. See Comments Touching OS Low Normal Liquor Volume Oligohydramnios Polyhydramnios Raised Not Checked Image Quality Fair Good Poor Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 2 of 21 The Radiology Information Solution 106740585 Please enter the measurements in mm and press [Enter]. To type additional comments left click beneath and begin typing. LONG BONES (mm) Side Press [Enter] in [Side] for another drop down list Both/ Left/ Right Femur Foot Area Humerus Radius Tibia Ulna Size Enter in mm. Press [Enter] in [Size] for another drop down list. INVASIVE INVEST None No additional fields to complete Amniocentesis Performed by- [F4] to select Enter in mm Liquor – Not Entered/ Clear/ Heavily blood stained/ Tinge of blood Through placenta- Blank/ Not performed/ Performed Location- [F4] to select a Referral Source CVS Tick to select. Press [Enter] for another drop down list. Choroid plexus cysts Golf ball Soft Markers Hyperechoic bowel Nuchal pad Renal pelvis dilation Short femur Fetal sex appears Last Updated: DC 04/07/2011 Not Checked Female Healthcare Software Systems – Commercial in Confidence Page 3 of 21 Male Not Asked Unknown Patient aware of sex Tick if Yes ANOMALY SUMMARY None No additional fields to complete Complex anomaly Aneuploidy Conjoined twins Hydrops Noonans Appearance suggests Other Twin to twin transfusion T13 T18 T21 XO CNS HEAD AND NECK Head Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Anencephaly Banana cerebellar sign Encephalocoele Appearance Suggests Hydrocephalus Lemon sign Holoprosencephaly Strawberry sign Uncertain diagnosis Incomplete Views Head continued Normal Seen Unseen Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 4 of 21 The Radiology Information Solution 106740585 Lips & Nostrils Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Cleft Lip Area Left Midline Right Micronathism Appearance Suggests Palate Uncertain diagnosis Incomplete Views Lips & Nostrils Normal Seen Unseen Lens Side Appearance Suggests Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Missing Uncertain diagnosis Incomplete Views Lens continued Normal Seen Unseen Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Limb body wall Other Other Incomplete Views Normal Seen Unseen Spine Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Lumbar Sacral Appearance Suggests Thoracic Agenesis Spina bifida Teratoma Uncertain diagnosis Incomplete Views Spine continued Normal Seen Unseen Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 5 of 21 SKELETAL Arms Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Other Appearance Suggests Radial aplasia Uncertain diagnosis Incomplete Views Arms continued Normal Seen Unseen Legs Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Skeletal dysplasia Appearance Suggests Other Uncertain diagnosis Incomplete Views Legs continued Normal Seen Unseen Hands Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Held in flexion Overlapping fingers Appearance Suggests Missing digits Other Polydactyly Uncertain diagnosis Incomplete Views Hands continued Normal Seen Unseen Feet Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Mild Severity Possible Severe Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 6 of 21 The Radiology Information Solution 106740585 Other Appearance Suggests Rocker bottom feet Talipes Uncertain diagnosis CARDIO VASCULAR Heart Press [Enter] in the [Appearance Suggests] for another drop down list. Appears abnormal- will display Normal 4 chambers view. Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Press [Enter] in the [Appearance Suggests] for another drop down list. Aortic atresia Aortic stenosis AVSD Double outlet of right ventricle Hypoplastic left heart syndrome Appearance Suggests Hypoplastic right heart syndrome Mitral atresia Mitral stenosis Other Pulmonary atresia Pulmonary stenosis Tricuspid atresia Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 7 of 21 Tricuspid stenosis Transposition of great vessels Uncertain diagnosis VSD Heart continued Press [Enter] in the [Appearance Suggests] for another drop down list. No abnormality seen on extended views- will display Normal 4 chambers view Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Heart continued Press [Enter] in the [Appearance Suggests] for another drop down list. Incomplete views- no additional fields No abnormality seen on standard views- will display Normal 4 chambers view Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Diaphragm Press [Enter] in [Appearance Suggests] for another drop down list. Abnormal- will display Appearance suggests Congenital diaphragmatic hernia Other Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 8 of 21 The Radiology Information Solution 106740585 THORAX Congenital adenomatoid malformation Pericardial effusion Thorax Incomplete views Normal Other Pleural effusion ABDOMEN Abdomen Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Ascites ASD Dilated bowel Appearance suggests Gastroschisis Ovarian cyst Omphalocoele Other Uncertain diagnosis Vascular malformation Incomplete views Abdomen continued Normal Seen Unseen Stomach Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Congenital diaphragmatic hernia Appearance suggests Duodenal atresia Other Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 9 of 21 Incomplete views Stomach continued Normal Seen Unseen UROGENITAL Kidneys Side Press [Enter] in the [Appearance Suggests] for another drop down list. Appears abnormal- will display Both/ Left/ Right Renal cyst Dysplastic kidney Horseshoe kidney Hydronephrosis Appearance suggests Hydroureter Multicystic dysplastic disease Other Polycystic kidneys Pelvic kidney Uncertain diagnosis Incomplete views Kidneys continued No evidence of abnormality seen Renal pelvis dilation Not seen Bladder Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Mega cystis Other Appearance suggests Prune belly syndrome Posterior urethral valves Uncertain diagnosis Ureterocoele Incomplete views Bladder continued Normal Seen Unseen Patient aware of ? abnormality Tick to select ‘Yes’ 1 / 5 (Remote) 2/5 Degree of confidence 3/5 4/5 5 / 5 (Confident) ADDITIONAL OPTIONS FOR ANOMALY SUMMARY Details Routine 3rd trimester views Routine views obtained Print summary Twins abnormality The same fields as ‘Complex Anomaly’ appear No additional fields The same fields as ‘Complex Anomaly’ appear To type additional comments left click beneath Last Updated: DC 04/07/2011 and begin typing. Healthcare Software Systems – Commercial in Confidence Page 10 of 21 The Radiology Information Solution 106740585 Obstetric Biophysical Scan Form BIOPHYSICAL SCAN (NW) BIOPHYSICAL SCAN (NW) More Than One Fetal heartbeat Not Present Present Breech Breech Legs Extended Footling Breech Breech Maternal Left Breech Maternal Right Cephalic Presentation Cephalic Maternal Left Cephalic Maternal Right Head to Mat. Left Oblique Lie Heat to Mat. Right Transverse Lie Vertical Fetal Movements Stomach / Diaphragm Kidneys See comments / Seen / Not seen Bladder Anterior Fundal Placenta Left Lateral Posterior Right Lateral Abutting OS Clear of OS Covering OS Site Low, clear of OS Low Lying Overlying OS See Comments Touching OS Liquor Volume Last Updated: DC 04/07/2011 Low – Additional fields will appear to complete AFI values. Normal Healthcare Software Systems – Commercial in Confidence Page 11 of 21 Oligohydramnios – Additional fields will appear to complete AFI values. Polyhydramnios – Additional fields will appear to complete AFI values. Raised – Additional fields will appear to complete AFI values. Umbilical Artery Dopper EDF Absent / Present / Reversed PI Pulsatility Index RI Resistivity Index Enter as required S/D Systolic / Diastolic Ratio Mid-cerebal EDF Artery Dopper Absent / Present / Reversed PI Pulsatility Index RI Resistivity Index Enter as required S/D Systolic / Diastolic Ratio Please enter the measurements in mm and press [Enter]. Please press [F4] in [EFW by] to select. EFW- Estimated Fetal Weight C – Campbell AC H1 – Hadlock AC + FL H2 – Hadlock HC + AC + FL S – Shephard AC + BPD Please enter a Biophysical Profile value of 0 or 2. To type additional comments left click beneath Last Updated: DC 04/07/2011 and begin typing. Healthcare Software Systems – Commercial in Confidence Page 12 of 21 The Radiology Information Solution 106740585 Obstetric Outcome Scan Form OUTCOME SCAN (NW) OUTCOME SCAN (NW) Fetal Identifier Complete as required Pregnancy Completion Enter in weeks and days Date Complete in DD/MM/YYYY format or press [F4] for the calendar Unknown Delivery Location Hospital Incidental Delivery Elsewhere Tertiary Centre Weight Enter in grams Congenital Abnormality Abnormality Suspected Antenatally Tick to select Suspected Correctly Referral to other Tick to select. Press [F4] for lookup to enter the Referral Source details. Not checked Female Fetal Sex Appears Male Not Asked Unknown Post Mortem Tick to select Pregnancy Outcome Alive with congenital anomaly Alive, no abnormality Intrauterine death Miscarriage < 13 weeks Neonatal death Termination for abnormality Social termination of pregnancy Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 13 of 21 ANOMALY SUMMARY None No additional fields to complete Complex anomaly Aneuploidy Conjoined twins Hydrops Noonans Appearance suggests Other Twin to twin transfusion T13 T18 T21 XO CNS HEAD AND NECK Head Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Anencephaly Banana cerebellar sign Encephalocoele Appearance Suggests Hydrocephalus Lemon sign Holoprosencephaly Strawberry sign Uncertain diagnosis Incomplete Views Head continued Normal Seen Unseen Lips & Nostrils Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Cleft Lip Area Left Midline Right Appearance Suggests Last Updated: DC 04/07/2011 Micronathism Healthcare Software Systems – Commercial in Confidence Page 14 of 21 The Radiology Information Solution 106740585 Palate Uncertain diagnosis Incomplete Views Lips & Nostrils Normal Seen Unseen Lens Side Appearance Suggests Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Missing Uncertain diagnosis Incomplete Views Lens continued Normal Seen Unseen Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Limb body wall Other Other Incomplete Views Normal Seen Unseen Spine Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Lumbar Sacral Appearance Suggests Thoracic Agenesis Spina bifida Teratoma Uncertain diagnosis Incomplete Views Spine continued Normal Seen Unseen Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 15 of 21 SKELETAL Arms Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Other Appearance Suggests Radial aplasia Uncertain diagnosis Incomplete Views Arms continued Normal Seen Unseen Legs Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Skeletal dysplasia Appearance Suggests Other Uncertain diagnosis Incomplete Views Legs continued Normal Seen Unseen Hands Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Held in flexion Overlapping fingers Appearance Suggests Missing digits Other Polydactyty Uncertain diagnosis Incomplete Views Hands continued Normal Seen Unseen Feet Side Press [Enter] in [Appearance Suggests] for another drop down list Appears abnormal- will display Both/ Left/ Right Mild Severity Possible Severe Other Appearance Suggests Rocker bottom feet Talipes Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 16 of 21 The Radiology Information Solution 106740585 CARDIO VASCULAR Heart Press [Enter] in the [Appearance Suggests] for another drop down list. Appears abnormal- will display Normal 4 chambers view. Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Press [Enter] in the [Appearance Suggests] for another drop down list. Aortic atresia Aortic stenosis AVSD Double outlet of right ventricle Hypoplastic left heart syndrome Hypoplastic right heart syndrome Appearance Suggests Mitral atresia Mitral stenosis Other Pulmonary atresia Pulmonary stenosis Tricuspid atresia Tricuspid stenosis Transposition of great vessels Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 17 of 21 VSD Heart continued Press [Enter] in the [Appearance Suggests] for another drop down list. No abnormality seen on extended views- will display Normal 4 chambers view Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Heart continued Press [Enter] in the [Appearance Suggests] for another drop down list. Incomplete views- no additional fields No abnormality seen on standard views- will display Normal 4 chambers view Aortic arch in sagittal Aortic arch in transverse Aortic outflow Ductal arch in sagittal Ductal arch in transverse Right to left flow in foramen ovale All features seen Inferior vena cava Anatomy Visualised Left pulmonary branch Normal heart size Neck vessels from aorta Normal orientation Offset crux Pulmonary outflow Pulmonary veins Right atrium = left atrium Right pulmonary branch Right ventricle = left ventricle Superior vena cava Diaphragm Press [Enter] in [Appearance Suggests] for another drop down list. Abnormal- will display Appearance suggests Congenital diaphragmatic hernia Other Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 18 of 21 The Radiology Information Solution 106740585 THORAX Congenital adenomatoid malformation Pericardial effusion Thorax Incomplete views Normal Other Pleural effusion ABDOMEN Abdomen Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Ascites ASD Dilated bowel Appearance suggests Gastroschisis Ovarian cyst Omphalocoele Other Uncertain diagnosis Vascular malformation Incomplete views Abdomen continued Normal Seen Unseen Stomach Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Congenital diaphragmatic hernia Appearance suggests Duodenal atresia Other Uncertain diagnosis Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 19 of 21 Incomplete views Stomach continued Normal Seen Unseen UROGENITAL Kidneys Side Press [Enter] in the [Appearance Suggests] for another drop down list. Appears abnormal- will display Both/ Left/ Right Renal cyst Dysplastic kidney Horseshoe kidney Hydronephrosis Appearance suggests Hydroureter Multicystic dysplastic disease Other Polycystic kidneys Pelvic kidney Uncertain diagnosis Incomplete views Kidneys continued No evidence of abnormality seen Renal pelvis dilation Not seen Bladder Press [Enter] in the [Appearance Suggests] for another drop down list. Abnormal- will display Mega cystis Other Appearance suggests Prune belly syndrome Posterior urethral valves Uncertain diagnosis Ureterocoele Incomplete views Bladder continued Normal Seen Unseen Patient aware of ? abnormality Tick to select ‘Yes’ 1 / 5 (Remote) 2/5 Degree of confidence 3/5 4/5 5 / 5 (Confident) ADDITIONAL OPTIONS FOR ANOMALY SUMMARY Details Routine 3rd trimester views Routine views obtained Print summary Twins abnormality The same fields as ‘Complex Anomaly’ appear No additional fields The same fields as ‘Complex Anomaly’ appear To type additional comments left click beneath and begin typing. OBSTETRIC ULTRASOUND SET-UP AND CONFIGURATION SETTINGS Please refer to CRIS CRIB RIS_CRIB296_Obstetric_Reporting_Configuration.doc Last Updated: DC 04/07/2011 Healthcare Software Systems – Commercial in Confidence Page 20 of 21 The Radiology Information Solution 106740585 Document Control Title Author File Ref. RIS_CRIB297_02.09.10e_Fetal_Anomaly_Module_v1.1 Date Created David Costin CRIB297 01/09/2009 Approval Sign-off Owner Role Method of approval Date David Costin Trainer/ Application Specialist Verbal 01/09/2009 Approver Role Method of approval Date Helen Richards Project Lead Verbal 01/09/2009 Change History Issue Date 1.0 01/09/2009 1.1 04/07/2011 Author / Editor DC DC Review Date 04/07/2011 Last Updated: DC 04/07/2011 Details of Change First Issue Amendments to version number for 2.09.10e Healthcare Software Systems – Commercial in Confidence Page 21 of 21
