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Volver a la introducción a las inferencias de RI
El campo kind es limitedOrderDiscrepancy.
Se crea si hay un orden limitado, lo que significa que no todas las partes del cuerpo y las medidas de un orden completo correspondiente (consulte Inferencia de discrepancia de orden completa) deben estar en el texto, pero todas las partes y medidas del cuerpo del orden completo están presentes en el texto.
Ejemplo sin extensiones de token:
{
"kind": "limitedOrderDiscrepancy",
"orderType": {
"extension": [],
"coding": [
{
"code": "76705",
"system": "Current Procedural Terminology",
"display": "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)"
}
]
},
"presentBodyParts": [
{
"extension": [],
"coding": [
{
"code": "RID58",
"system": "RADLEX ONTOLOGY",
"display": "Liver"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID187",
"system": "RADLEX ONTOLOGY",
"display": "GALLBLADDER"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID199",
"system": "RADLEX ONTOLOGY",
"display": "COMMON BILE DUCT"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID170",
"system": "RADLEX ONTOLOGY",
"display": "PANCREAS"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID86",
"system": "RADLEX ONTOLOGY",
"display": "SPLEEN"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID29663",
"system": "RADLEX ONTOLOGY",
"display": "LEFT KIDNEY"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID29662",
"system": "RADLEX ONTOLOGY",
"display": "RIGHT KIDNEY"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID905",
"system": "RADLEX ONTOLOGY",
"display": "ABDOMINAL AORTA"
}
]
},
{
"extension": [],
"coding": [
{
"code": "RID1178",
"system": "RADLEX ONTOLOGY",
"display": "INFERIOR VENA CAVA"
}
]
}
],
"presentBodyPartMeasurements": []
}
En este ejemplo, el pedido es limitado, pero el documento está completo (contiene todos los elementos necesarios para un pedido completo), por eso la discrepancia.
El campo ordertype contiene una codificación, con uno de los siguientes códigos CPT:
| Código | Mostrar |
|---|---|
| 76705 | ULTRASONIDO ABDOMINAL EN TIEMPO REAL CON DOCUMENTACIÓN DE IMÁGENES; LIMITADO (POR EJEMPLO, DE UN SOLO ÓRGANO, CUADRANTE, SEGUIMIENTO) |
| 76857 | ULTRASONIDO PÉLVICO EN TIEMPO REAL CON DOCUMENTACIÓN DE IMÁGENES; LIMITADO O DE SEGUIMIENTO |
| 76775 | ULTRASONIDO RETROPERITONEAL (POR EJEMPLO, RENAL, AORTA, NÓDULOS), EN TIEMPO REAL CON DOCUMENTACIÓN DE IMÁGENES; LIMITADO |
| 76642 | ULTRASONIDO DE MAMA LIMITADO |
Cada uno de estos corresponde a uno de los órdenes completos en la Inferencia de discrepancia de orden completo. Los campos presentBodyParts y/o presentBodyPartsMeasurements están configurados para contener partes del cuerpo (códigos de Radlex) que están presentes o cuyas medidas están disponibles. Las extensiones de token se refieren a partes del cuerpo o medidas que están presentes (o palabras que las implican).
Consulte la Inferencia de discrepancia de orden completo sobre las discrepancias de orden completo para determinar cuándo un texto se considera completo.
Ejemplos de json de solicitud y respuesta:
{
"jobData": {
"configuration": {
"inferenceOptions": {
"followupRecommendationOptions": {
"includeRecommendationsWithNoSpecifiedModality": false,
"includeRecommendationsInReferences": false,
"provideFocusedSentenceEvidence": false
},
"findingOptions": {
"provideFocusedSentenceEvidence": false
}
},
"inferenceTypes": ["limitedOrderDiscrepancy"],
"locale": "en-US",
"verbose": false,
"includeEvidence": false
},
"patients": [
{
"id": "111111",
"details": {
"sex": "male",
"birthDate" : "1959-11-11T19:00:00+00:00",
"clinicalInfo": [
{
"resourceType": "Observation",
"status": "unknown",
"code": {
"coding": [
{
"system": "http://www.nlm.nih.gov/research/umls",
"code": "C0018802",
"display": "MalignantNeoplasms"
}
]
},
"valueBoolean": "true"
}
]
},
"encounters": [
{
"id": "encounterid1",
"period": {
"start": "2021-8-28T00:00:00",
"end": "2021-8-28T00:00:00"
},
"class": "inpatient"
}
],
"patientDocuments": [
{
"type": "note",
"clinicalType": "radiologyReport",
"id": "docid1",
"language": "en",
"authors": [
{
"id": "authorid1",
"fullName": "authorname1"
}
],
"specialtyType": "radiology",
"createdAt": "2021-8-28T00:00:00",
"administrativeMetadata": {
"orderedProcedures": [
{
"code": {
"coding": [
{
"system": "https://loinc.org",
"code": "30704-1",
"display": "US ABDOMEN LIMITED"
}
]
},
"description": "US ABDOMEN LIMITED"
}
],
"encounterId": "encounterid1"
},
"content": {
"sourceType": "inline",
"value" : "\nHISTORY: 49-year-old male with a history of tuberous sclerosis presenting with epigastric pain and diffuse tenderness. The patient was found to have pericholecystic haziness on CT; evaluation for acute cholecystitis.\n\nTECHNIQUE: Ultrasound evaluation of the abdomen was performed. Comparison is made to the prior abdominal ultrasound (2004) and to the enhanced CT of the abdomen and pelvis (2014).\n\nFINDINGS:\n\nThe liver is elongated, measuring 19.3 cm craniocaudally, and is homogeneous in echotexture without evidence of focal mass lesion. The liver contour is smooth on high resolution images. There is no appreciable intra- or extrahepatic biliary ductal dilatation, with the visualized extrahepatic bile duct measuring up to 6 mm. There are multiple shadowing gallstones, including within the gallbladder neck, which do not appear particularly mobile. In addition, there is thickening of the gallbladder wall up to approximately 7 mm with probable mild mural edema. There is no pericholecystic fluid. No sonographic Murphy's sign was elicited; however the patient reportedly received pain medications in the emergency department.\n\nThe pancreatic head, body and visualized portions of the tail are unremarkable. The spleen is normal in size, measuring 9.9 cm in length.\n\nThe kidneys are normal in size. The right kidney measures 11.5 x 5.2 x 4.3 cm and the left kidney measuring 11.8 x 5.3 x 5.1 cm. There are again multiple bilateral echogenic renal masses consistent with angiomyolipomas, in keeping with the patient's history of tuberous sclerosis. The largest echogenic mass on the right is located in the upper pole and measures 1.2 x 1.3 x 1.3 cm. The largest echogenic mass on the left is located within the renal sinus and measures approximately 2.6 x 2.7 x 4.6 cm. Additional indeterminate renal lesions are present bilaterally and are better characterized on CT. There is no hydronephrosis.\n\nNo ascites is identified within the upper abdomen.\n\nThe visualized portions of the upper abdominal aorta and IVC are normal in caliber.\n\nIMPRESSION:\n\n1. Numerous gallstones associated with gallbladder wall thickening and probable gallbladder mural edema, highly suspicious for acute cholecystitis in this patient presenting with epigastric pain and pericholecystic hazy density identified on CT. Although no sonographic Murphy sign was elicited, evaluation is limited secondary to reported prior administration of pain medication. Thus, clinical correlation is required. No evidence of biliary ductal dilation.\n\n2. There are again multiple bilateral echogenic renal masses consistent with angiomyolipomas, in keeping with the patient's history of tuberous sclerosis. Additional indeterminate renal lesions are present bilaterally and are better characterized on CT and MR.\n\nThese findings were discussed with Dr. Doe at 5:05 p.m. on 1/1/15."
}
}
]
}
]
}
}
{
"result": {
"patientResults": [
{
"patientId": "111111",
"inferences": [
{
"kind": "limitedOrderDiscrepancy",
"orderType": {
"coding": [
{
"system": "http://loinc.org",
"code": "24558-9",
"display": "US Abdomen"
}
]
},
"presentBodyParts": [
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID58",
"display": "LIVER"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID187",
"display": "GALLBLADDER"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID199",
"display": "COMMON BILE DUCT"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID170",
"display": "PANCREAS"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID86",
"display": "SPLEEN"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID29663",
"display": "LEFT KIDNEY"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID29662",
"display": "RIGHT KIDNEY"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID905",
"display": "ABDOMINAL AORTA"
}
]
},
{
"coding": [
{
"system": "http://radlex.org",
"code": "RID1178",
"display": "INFERIOR VENA CAVA"
}
]
}
],
"presentBodyPartMeasurements": []
}
]
}
],
"modelVersion": "2025-03-17"
},
"id": "fca111",
"createdAt": "2025-04-30T11:20:48Z",
"expiresAt": "2025-05-01T11:20:48Z",
"updatedAt": "2025-04-30T11:20:53Z",
"status": "succeeded"
}