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Packagede.medizininformatikinitiative.kerndatensatz.patho
Resource TypeSpecimen
IdSpecimen-mii-exa-patho-breast-resection-sample.json
FHIR VersionR4

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Source1

{
  "resourceType": "Specimen",
  "id": "mii-exa-patho-breast-resection-sample",
  "meta": {
    "profile": [
      "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-specimen|2027.0.0-ballot"
    ]
  },
  "type": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "397199005",
        "display": "Specimen from breast obtained by excision"
      }
    ]
  },
  "collection": {
    "bodySite": {
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Specimen.collection.bodySite",
          "valueReference": {
            "reference": "BodyStructure/mii-exa-patho-left-breast-body-structure"
          }
        }
      ],
      "coding": [
        {
          "code": "33564002",
          "system": "http://snomed.info/sct",
          "display": "Structure of lower outer quadrant of breast"
        }
      ]
    },
    "collector": {
      "reference": "Practitioner/mii-exa-patho-practitioner-2346545"
    },
    "collectedDateTime": "2025-02-05T10:00:00+01:00",
    "method": {
      "coding": [
        {
          "code": "237371007",
          "system": "http://snomed.info/sct",
          "display": "Wide local excision of breast lesion"
        }
      ]
    }
  },
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "code": "PLAC",
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203"
          }
        ]
      },
      "system": "https://senologie.example-hospital.de/fhir/specimen/placer",
      "value": "OP25_210_A"
    },
    {
      "type": {
        "coding": [
          {
            "code": "FILL",
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203"
          }
        ]
      },
      "system": "https://pathologie.example-hospital.de/fhir/fn/befundbericht",
      "value": "E_25_210_A"
    }
  ],
  "accessionIdentifier": {
    "system": "https://pathologie.example-hospital.de/fhir/fn/befundbericht",
    "value": "E_25_210"
  },
  "status": "available",
  "subject": {
    "reference": "Patient/mii-exa-patho-patient-34545"
  },
  "request": [
    {
      "reference": "ServiceRequest/mii-exa-patho-request"
    }
  ],
  "extension": [
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Specimen.feature",
      "extension": [
        {
          "url": "type",
          "valueCodeableConcept": {
            "coding": [
              {
                "code": "735083009",
                "system": "http://snomed.info/sct",
                "display": "Part of left breast"
              }
            ]
          }
        },
        {
          "url": "description",
          "valueString": "Praeoperative radiologische Drahtmarkierung der Biopsiestelle"
        }
      ]
    },
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Specimen.feature",
      "extension": [
        {
          "url": "type",
          "valueCodeableConcept": {
            "coding": [
              {
                "code": "3680001000004109",
                "system": "http://snomed.info/sct",
                "display": "Anterior surgical margin"
              }
            ]
          }
        },
        {
          "url": "description",
          "valueString": "Fadenmarkierung lang anterior"
        }
      ]
    },
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Specimen.feature",
      "extension": [
        {
          "url": "type",
          "valueCodeableConcept": {
            "coding": [
              {
                "code": "880001000004108",
                "system": "http://snomed.info/sct",
                "display": "Distal surgical margin"
              }
            ]
          }
        },
        {
          "url": "description",
          "valueString": "Fadenmarkierung 2x kurz distal"
        }
      ]
    }
  ],
  "container": [
    {
      "type": {
        "coding": [
          {
            "code": "434746001",
            "system": "http://snomed.info/sct",
            "display": "Specimen vial"
          }
        ]
      },
      "additiveReference": {
        "reference": "Substance/mii-exa-patho-neutral-buffered-formalin"
      }
    }
  ],
  "note": [
    {
      "text": "BET-Exzisionspraeparat Mamma links, unterer aeusserer Quadrant, 5 Uhr, 50 mm von der Mamille. Drahthaekchen und zwei Fadenmarkierungen."
    }
  ]
}