FHIRsmith: DiagnosticReport/DiagnosticReport-r2bo-informe-biopsia-ex.json

FHIR IG analytics

Package	hl7.fhir.cl.minsal.r2bo
Resource Type	DiagnosticReport
Id	DiagnosticReport-r2bo-informe-biopsia-ex.json
FHIR Version	R4

Resources that use this resource

No resources found

Resources that this resource uses

No resources found

Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: DiagnosticReport r2bo-informe-biopsia-ex

Profile: Perfil del Reporte de Anatomía Patológica

Informe de Biopsia de Mama (Pathology (gross & histopath, not surgical))

Subject

Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))

Reported

2021-08-01 10:00:00-0400

Performer

PractitionerRole MÉDICO CIRUJANO

Identifier

r2bo-2020-0001

Report Details

Code

Value

Flags

When For

Pathology report microscopic observation in Specimen

Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos

Final

2021-06-01 12:00:00-0400

Macroscopic observation [Interpretation] in Specimen Narrative

Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista

Final

2021-06-01 12:00:00-0400

Pathologic TNM stage grouping (observable entity)

Final

2021-06-01 12:00:00-0400

Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral

Coded Conclusions:

Carcinoma ductal infiltrante
Mama

Source1

{
  "resourceType": "DiagnosticReport",
  "id": "r2bo-informe-biopsia-ex",
  "meta": {
    "profile": [
      "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition",
      "valueReference": {
        "reference": "Composition/r2bo-documento-biopsia-ex"
      }
    }
  ],
  "identifier": [
    {
      "value": "r2bo-2020-0001"
    }
  ],
  "basedOn": [
    {
      "reference": "ServiceRequest/r2bo-solicitud-informe-apa-ej"
    }
  ],
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code": "PAT",
          "display": "Pathology (gross & histopath, not surgical)"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "66110-8"
      }
    ],
    "text": "Informe de Biopsia de Mama"
  },
  "subject": {
    "reference": "Patient/paciente-requiere-examen"
  },
  "issued": "2021-08-01T10:00:00-04:00",
  "performer": [
    {
      "reference": "PractitionerRole/r2bo-anatopatologo-hospital"
    }
  ],
  "specimen": [
    {
      "reference": "Specimen/r2bo-specimen-example"
    }
  ],
  "result": [
    {
      "reference": "Observation/r2bo-observacion-microscopica-ex"
    },
    {
      "reference": "Observation/r2bo-observacion-macroscopica-ex"
    },
    {
      "reference": "Observation/r2bo-estadificacion-tnm-ex"
    }
  ],
  "conclusion": "Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral",
  "conclusionCode": [
    {
      "id": "Morfologico",
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "82711006"
        },
        {
          "system": "http://terminology.hl7.org/CodeSystem/icd-o-3",
          "code": "8500/3"
        }
      ],
      "text": "Carcinoma ductal infiltrante"
    },
    {
      "id": "Topografico",
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "76752008"
        },
        {
          "system": "http://terminology.hl7.org/CodeSystem/icd-o-3",
          "code": "C50.9"
        }
      ],
      "text": "Mama"
    }
  ]
}