MII IG Modul Patho - Local Development build (v2027.0.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: mii-exa-patho-report

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{
  "resourceType" : "DiagnosticReport",
  "id" : "mii-exa-patho-report",
  "meta" : {
    "profile" : [
      🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2027.0.0-ballot"
    ]
  },
  "language" : "en",
  "text" : {
    "status" : "generated",
    "div" : "<div xml:lang=\"en\" lang=\"en\"><hr/><p><b>English</b></p><hr/><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport mii-exa-patho-report</b></p><a name=\"en-mii-exa-patho-report\"> </a><a name=\"en-hcmii-exa-patho-report\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-mii-pr-patho-report.html\">MII PR Patho Report</a> version: 2027.0.0-ballot</p></div><h2><span title=\"Codes:{http://loinc.org 60568-3}\">Pathology synoptic report</span> </h2><table class=\"grid\"><tr><td>Subject</td><td>Max Mustermann  Male, DoB: 1959-08-24</td></tr><tr><td>Relevant Time</td><td>2021-06-01</td></tr><tr><td>Performer</td><td> <a href=\"Practitioner-mii-exa-patho-practitioner-2346545.html\">Practitioner Sabine Schnitt </a></td></tr><tr><td>Identifier</td><td> Accession ID/E21.12345</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td></tr><tr><td><a href=\"Observation-mii-exa-patho-macro-grouper-a.html\"><span title=\"Codes:{http://loinc.org 22634-0}\">Pathology report gross observation Narrative</span></a></td><td/><td>Final</td></tr><tr><td><a href=\"Observation-mii-exa-patho-micro-grouper-a.html\"><span title=\"Codes:{http://loinc.org 22635-7}\">Pathology report microscopic observation Narrative Other stain</span></a></td><td>Specimen A: Prostatastanze mit herdförmiger kontinuierlicher Infiltration durch unscharf begrenzte Verbände eines kleintubulär wachse (Gleason-Muster 3), die sich zwischen ortständige Drüsen schieben und ca. 30% der Schnittfläche des Zylinders...</td><td>Final</td></tr><tr><td><a href=\"Observation-mii-exa-patho-diagnostic-conclusion-grouper.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td/><td>Final</td></tr></table><p>Well-differentiated acinar adenocarcinoma of the prostate, ISUP grade group 1</p><p><b>Coded Conclusions:</b></p><ul><li><span title=\"Codes:{http://snomed.info/sct 1525761000004109}\">International Society of Urological Pathology histologic grade group 1</span></li></ul></div>"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "ACSN",
            "display" : "Accession ID"
          }
        ]
      },
      "system" : "https://pathologie.klinikum-karlsruhe.de/fhir/fn/befundbericht",
      "value" : "E21.12345"
    }
  ],
  "basedOn" : [
    {
      🔗 "reference" : "ServiceRequest/mii-exa-patho-request"
    }
  ],
  "status" : "final",
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "60568-3",
        "display" : "Pathology synoptic report"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/mii-exa-patho-patient-12345"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/mii-exa-patho-encounter-12345"
  },
  "effectiveDateTime" : "2021-06-01",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/mii-exa-patho-practitioner-2346545"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/mii-exa-patho-prostate-tru-cut-biopsy-sample"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/mii-exa-patho-macro-grouper-a"
    },
    {
      🔗 "reference" : "Observation/mii-exa-patho-micro-grouper-a"
    },
    {
      🔗 "reference" : "Observation/mii-exa-patho-diagnostic-conclusion-grouper"
    }
  ],
  "media" : [
    {
      "comment" : "H&E section of a prostate core biopsy, infiltrated by carcinoma cell clusters, photographically documented",
      "link" : {
        🔗 "reference" : "Media/mii-exa-patho-attached-image"
      }
    }
  ],
  "conclusion" : "Well-differentiated acinar adenocarcinoma of the prostate, ISUP grade group 1",
  "conclusionCode" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "1525761000004109"
        }
      ]
    }
  ]
}