FHIR IG analytics| Package | lt.hl7.fhir.breast |
| Resource Type | QuestionnaireResponse |
| Id | QuestionnaireResponse-questionnaireresponse-pathology-example.json |
| FHIR Version | R5 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
English
Generated Narrative: QuestionnaireResponse questionnaireresponse-pathology-example
Language: en
| LinkID | Text | Definition | Answer |
|---|---|---|---|
  questionnaireresponse-pathology-example | Questionnaire:Questionnaire: Pathological Histological Examination ESPBI Form (LT Breast) | ||
  grp-referral | Referral to perform pathology test | ||
 grp-patient | Patient information | ||
 patient-personal-code | Personal code | 48501019999 | |
| patient-name | Name | Janette | |
| patient-surname | Surname | Petrauskaite | |
| patient-birth-date | Date of birth | 1985-01-01 | |
| patient-age | Age | 40 | |
 patient-gender | Gender | AdministrativeGender: female (Female) | |
| grp-specimen-dates | Specimen dates | ||
| specimen-collection-date | Date of material collection | 2025-03-07T09:15:00+02:00 | |
| specimen-shipment-date | Shipment / formation date | 2025-03-07T10:00:00+02:00 | |
| grp-clinical-diagnosis | Clinical diagnosis | ||
| diagnosis-icd10-code | Clinical diagnosis ICD-10-AM code | C50.4 | |
| diagnosis-name | Clinical diagnosis name | Malignant neoplasm of upper-outer quadrant of breast | |
| grp-material | Material fixation | ||
| fixation-type | Material fixation type | Breast questionnaire answer options (illustrative): fixation-formalin (Fixed (10% formalin buffered solution)) | |
| grp-previous-procedures | Previous procedures and key clinical data | ||
| previous-procedures | Key clinical data | Breast questionnaire answer options (illustrative): proc-none (No important information) | |
| previous-procedures-other | Other information | ||
| grp-special-tests | Special tests | ||
| special-tests-required | Special tests required | IHC panel (ER, PR, HER2, Ki67) | |
| grp-radiological-data | Radiological examination data | ||
| radiology-performed | Radiological examination performed | Breast questionnaire answer options (illustrative): yes (Yes) | |
| radiology-exam-type | Examination type | ||
| radiology-exam-date | Examination date | 2025-03-05 | |
| birads-right | BI-RADS right breast | Breast questionnaire answer options (illustrative): birads-1 (BI-RADS 1 – No changes found) | |
| birads-left | BI-RADS left breast | Breast questionnaire answer options (illustrative): birads-4 (BI-RADS 4 – Suspicious malignant finding) | |
| grp-operation | Operation details | ||
| operation-nature | Nature of operation | Breast questionnaire answer options (illustrative): op-thick-needle-biopsy (Thick needle biopsy) | |
| operation-other-details | Other operation details | ||
| grp-histological-sample | Description of histological sample / object | ||
| sample-container-info | Container information | 1 container, labelled 'Left breast UOQ, CNB' | |
| sample-biopsy-location | Biopsy location | Left breast, upper-outer quadrant, 2 o'clock position, 5 cm from nipple | |
| grp-macroscopic | Description of macroscopic examination | ||
| macro-biopsy-size | Biopsy size (mm) | 15 mm (Details: UCUM codemm = 'mm') | |
| macro-fragment-details | Fragment details | 4 tissue cores, pale grey, firm, longest 15 mm | |
| macro-notes | Notes | Entirely submitted in 2 cassettes | |
| grp-microscopic | Description of microscopic examination | ||
| microscopic-description | Microscopic examination description | Core biopsy fragments showing invasive carcinoma of no special type (NST). Tumour cells arranged in nests, cords and tubular structures, surrounded by desmoplastic stroma. Moderate nuclear pleomorphism, mitotic count 8/10 HPF. No definite in-situ component identified in this limited sample. | |
| grp-ihc | Immunohistochemistry (IHC) | ||
| ihc-er-status | Estrogen receptors ER | Breast questionnaire answer options (illustrative): ihc-strong (Strong (+++)) | |
| ihc-er-percent | ER expression in nuclei (%) | 90 % (Details: UCUM code% = '%') | |
| ihc-pr-status | Progesterone receptors PR | Breast questionnaire answer options (illustrative): ihc-moderate (Moderate (++)) | |
| ihc-pr-percent | PR expression in nuclei (%) | 60 % (Details: UCUM code% = '%') | |
| ihc-her2-status | HER2 status | Breast questionnaire answer options (illustrative): her2-borderline (HER2: expression borderline (2+)) | |
| ihc-her2-evaluation | HER2 evaluation | Breast questionnaire answer options (illustrative): her2-eval-2 (HER2 evaluation: 2+) | |
| ihc-ki67 | Ki67 proliferation index (%) | 25 % (Details: UCUM code% = '%') | |
| grp-molecular | Molecular studies | ||
| fish-result | FISH result | Breast questionnaire answer options (illustrative): fish-not-evaluated (FISH: not to be evaluated) | |
| fish-her2-average | HER2 average | ||
| fish-cep17-average | Average CEP17 | ||
| fish-her2-cep17-ratio | HER2/CEP17 ratio | ||
| cish-sish-result | CISH/SISH result | Breast questionnaire answer options (illustrative): cish-not-evaluated (CISH/SISH: not to be evaluated) | |
| grp-conclusion | Conclusion | ||
 conclusion-who-diagnosis | WHO Classification diagnosis | Invasive breast carcinoma of no special type (NST) (ICD-O 8500/3) | |
| conclusion-tumour-grade | Tumour grade | Breast questionnaire answer options (illustrative): grade-g2 (G2 (moderately differentiated)) | |
| conclusion-tumour-size | Tumour size (mm) | 18 mm (Details: UCUM codemm = 'mm') | |
| conclusion-lvi | Lymphovascular invasion | Breast questionnaire answer options (illustrative): lvi-0 (pLVI-0: not detected) | |
| Documentation for this format | |||
Lithuanian
Generated Narrative: QuestionnaireResponse questionnaireresponse-pathology-example
Language: en
| LinkID | Text | Definition | Answer |
|---|---|---|---|
| questionnaireresponse-pathology-example | Questionnaire:Questionnaire: Pathological Histological Examination ESPBI Form (LT Breast) | ||
| grp-referral | Referral to perform pathology test | ||
| grp-patient | Patient information | ||
| patient-personal-code | Personal code | 48501019999 | |
| patient-name | Name | Janette | |
| patient-surname | Surname | Petrauskaite | |
| patient-birth-date | Date of birth | 1985-01-01 | |
| patient-age | Age | 40 | |
| patient-gender | Gender | AdministrativeGender: female (Female) | |
| grp-specimen-dates | Specimen dates | ||
| specimen-collection-date | Date of material collection | 2025-03-07T09:15:00+02:00 | |
| specimen-shipment-date | Shipment / formation date | 2025-03-07T10:00:00+02:00 | |
| grp-clinical-diagnosis | Clinical diagnosis | ||
| diagnosis-icd10-code | Clinical diagnosis ICD-10-AM code | C50.4 | |
| diagnosis-name | Clinical diagnosis name | Malignant neoplasm of upper-outer quadrant of breast | |
| grp-material | Material fixation | ||
| fixation-type | Material fixation type | Breast questionnaire answer options (illustrative): fixation-formalin (Fixed (10% formalin buffered solution)) | |
| grp-previous-procedures | Previous procedures and key clinical data | ||
| previous-procedures | Key clinical data | Breast questionnaire answer options (illustrative): proc-none (No important information) | |
| previous-procedures-other | Other information | ||
| grp-special-tests | Special tests | ||
| special-tests-required | Special tests required | IHC panel (ER, PR, HER2, Ki67) | |
| grp-radiological-data | Radiological examination data | ||
| radiology-performed | Radiological examination performed | Breast questionnaire answer options (illustrative): yes (Yes) | |
| radiology-exam-type | Examination type | ||
| radiology-exam-date | Examination date | 2025-03-05 | |
| birads-right | BI-RADS right breast | Breast questionnaire answer options (illustrative): birads-1 (BI-RADS 1 – No changes found) | |
| birads-left | BI-RADS left breast | Breast questionnaire answer options (illustrative): birads-4 (BI-RADS 4 – Suspicious malignant finding) | |
| grp-operation | Operation details | ||
| operation-nature | Nature of operation | Breast questionnaire answer options (illustrative): op-thick-needle-biopsy (Thick needle biopsy) | |
| operation-other-details | Other operation details | ||
| grp-histological-sample | Description of histological sample / object | ||
| sample-container-info | Container information | 1 container, labelled 'Left breast UOQ, CNB' | |
| sample-biopsy-location | Biopsy location | Left breast, upper-outer quadrant, 2 o'clock position, 5 cm from nipple | |
| grp-macroscopic | Description of macroscopic examination | ||
| macro-biopsy-size | Biopsy size (mm) | 15 mm (Details: UCUM codemm = 'mm') | |
| macro-fragment-details | Fragment details | 4 tissue cores, pale grey, firm, longest 15 mm | |
| macro-notes | Notes | Entirely submitted in 2 cassettes | |
| grp-microscopic | Description of microscopic examination | ||
| microscopic-description | Microscopic examination description | Core biopsy fragments showing invasive carcinoma of no special type (NST). Tumour cells arranged in nests, cords and tubular structures, surrounded by desmoplastic stroma. Moderate nuclear pleomorphism, mitotic count 8/10 HPF. No definite in-situ component identified in this limited sample. | |
| grp-ihc | Immunohistochemistry (IHC) | ||
| ihc-er-status | Estrogen receptors ER | Breast questionnaire answer options (illustrative): ihc-strong (Strong (+++)) | |
| ihc-er-percent | ER expression in nuclei (%) | 90 % (Details: UCUM code% = '%') | |
| ihc-pr-status | Progesterone receptors PR | Breast questionnaire answer options (illustrative): ihc-moderate (Moderate (++)) | |
| ihc-pr-percent | PR expression in nuclei (%) | 60 % (Details: UCUM code% = '%') | |
| ihc-her2-status | HER2 status | Breast questionnaire answer options (illustrative): her2-borderline (HER2: expression borderline (2+)) | |
| ihc-her2-evaluation | HER2 evaluation | Breast questionnaire answer options (illustrative): her2-eval-2 (HER2 evaluation: 2+) | |
| ihc-ki67 | Ki67 proliferation index (%) | 25 % (Details: UCUM code% = '%') | |
| grp-molecular | Molecular studies | ||
| fish-result | FISH result | Breast questionnaire answer options (illustrative): fish-not-evaluated (FISH: not to be evaluated) | |
| fish-her2-average | HER2 average | ||
| fish-cep17-average | Average CEP17 | ||
| fish-her2-cep17-ratio | HER2/CEP17 ratio | ||
| cish-sish-result | CISH/SISH result | Breast questionnaire answer options (illustrative): cish-not-evaluated (CISH/SISH: not to be evaluated) | |
| grp-conclusion | Conclusion | ||
| conclusion-who-diagnosis | WHO Classification diagnosis | Invasive breast carcinoma of no special type (NST) (ICD-O 8500/3) | |
| conclusion-tumour-grade | Tumour grade | Breast questionnaire answer options (illustrative): grade-g2 (G2 (moderately differentiated)) | |
| conclusion-tumour-size | Tumour size (mm) | 18 mm (Details: UCUM codemm = 'mm') | |
| conclusion-lvi | Lymphovascular invasion | Breast questionnaire answer options (illustrative): lvi-0 (pLVI-0: not detected) | |
| Documentation for this format | |||
FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "questionnaireresponse-pathology-example",
"language": "en",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"questionnaire": "https://hl7.lt/fhir/breast/Questionnaire/questionnaire-pathology-lt-breast",
"status": "completed",
"subject": {
"reference": "Patient/example-patient-female"
},
"authored": "2025-03-10T14:30:00+02:00",
"item": [
{
"linkId": "grp-referral",
"text": "Referral to perform pathology test"
},
{
"linkId": "grp-patient",
"text": "Patient information",
"item": [
{
"linkId": "patient-personal-code",
"text": "Personal code",
"answer": [
{
"valueString": "48501019999"
}
]
},
{
"linkId": "patient-name",
"text": "Name",
"answer": [
{
"valueString": "Janette"
}
]
},
{
"linkId": "patient-surname",
"text": "Surname",
"answer": [
{
"valueString": "Petrauskaite"
}
]
},
{
"linkId": "patient-birth-date",
"text": "Date of birth",
"answer": [
{
"valueDate": "1985-01-01"
}
]
},
{
"linkId": "patient-age",
"text": "Age",
"answer": [
{
"valueInteger": 40
}
]
},
{
"linkId": "patient-gender",
"text": "Gender",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "female",
"display": "Female"
}
}
]
}
]
},
{
"linkId": "grp-specimen-dates",
"text": "Specimen dates",
"item": [
{
"linkId": "specimen-collection-date",
"text": "Date of material collection",
"answer": [
{
"valueDateTime": "2025-03-07T09:15:00+02:00"
}
]
},
{
"linkId": "specimen-shipment-date",
"text": "Shipment / formation date",
"answer": [
{
"valueDateTime": "2025-03-07T10:00:00+02:00"
}
]
}
]
},
{
"linkId": "grp-clinical-diagnosis",
"text": "Clinical diagnosis",
"item": [
{
"linkId": "diagnosis-icd10-code",
"text": "Clinical diagnosis ICD-10-AM code",
"answer": [
{
"valueString": "C50.4"
}
]
},
{
"linkId": "diagnosis-name",
"text": "Clinical diagnosis name",
"answer": [
{
"valueString": "Malignant neoplasm of upper-outer quadrant of breast"
}
]
}
]
},
{
"linkId": "grp-material",
"text": "Material fixation",
"item": [
{
"linkId": "fixation-type",
"text": "Material fixation type",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "fixation-formalin",
"display": "Fixed (10% formalin buffered solution)"
}
}
]
}
]
},
{
"linkId": "grp-previous-procedures",
"text": "Previous procedures and key clinical data",
"item": [
{
"linkId": "previous-procedures",
"text": "Key clinical data",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "proc-none",
"display": "No important information"
}
}
]
},
{
"linkId": "previous-procedures-other",
"text": "Other information"
}
]
},
{
"linkId": "grp-special-tests",
"text": "Special tests",
"item": [
{
"linkId": "special-tests-required",
"text": "Special tests required",
"answer": [
{
"valueString": "IHC panel (ER, PR, HER2, Ki67)"
}
]
}
]
},
{
"linkId": "grp-radiological-data",
"text": "Radiological examination data",
"item": [
{
"linkId": "radiology-performed",
"text": "Radiological examination performed",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "yes",
"display": "Yes"
}
}
]
},
{
"linkId": "radiology-exam-type",
"text": "Examination type",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "71651007",
"display": "Mammography"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "16310003",
"display": "Ultrasonography"
}
}
]
},
{
"linkId": "radiology-exam-date",
"text": "Examination date",
"answer": [
{
"valueDate": "2025-03-05"
}
]
},
{
"linkId": "birads-right",
"text": "BI-RADS right breast",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "birads-1",
"display": "BI-RADS 1 – No changes found"
}
}
]
},
{
"linkId": "birads-left",
"text": "BI-RADS left breast",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "birads-4",
"display": "BI-RADS 4 – Suspicious malignant finding"
}
}
]
}
]
},
{
"linkId": "grp-operation",
"text": "Operation details",
"item": [
{
"linkId": "operation-nature",
"text": "Nature of operation",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "op-thick-needle-biopsy",
"display": "Thick needle biopsy"
}
}
]
},
{
"linkId": "operation-other-details",
"text": "Other operation details"
}
]
},
{
"linkId": "grp-histological-sample",
"text": "Description of histological sample / object",
"item": [
{
"linkId": "sample-container-info",
"text": "Container information",
"answer": [
{
"valueString": "1 container, labelled 'Left breast UOQ, CNB'"
}
]
},
{
"linkId": "sample-biopsy-location",
"text": "Biopsy location",
"answer": [
{
"valueString": "Left breast, upper-outer quadrant, 2 o'clock position, 5 cm from nipple"
}
]
}
]
},
{
"linkId": "grp-macroscopic",
"text": "Description of macroscopic examination",
"item": [
{
"linkId": "macro-biopsy-size",
"text": "Biopsy size (mm)",
"answer": [
{
"valueQuantity": {
"value": 15,
"unit": "mm",
"system": "http://unitsofmeasure.org",
"code": "mm"
}
}
]
},
{
"linkId": "macro-fragment-details",
"text": "Fragment details",
"answer": [
{
"valueString": "4 tissue cores, pale grey, firm, longest 15 mm"
}
]
},
{
"linkId": "macro-notes",
"text": "Notes",
"answer": [
{
"valueString": "Entirely submitted in 2 cassettes"
}
]
}
]
},
{
"linkId": "grp-microscopic",
"text": "Description of microscopic examination",
"item": [
{
"linkId": "microscopic-description",
"text": "Microscopic examination description",
"answer": [
{
"valueString": "Core biopsy fragments showing invasive carcinoma of no special type (NST). Tumour cells arranged in nests, cords and tubular structures, surrounded by desmoplastic stroma. Moderate nuclear pleomorphism, mitotic count 8/10 HPF. No definite in-situ component identified in this limited sample."
}
]
}
]
},
{
"linkId": "grp-ihc",
"text": "Immunohistochemistry (IHC)",
"item": [
{
"linkId": "ihc-er-status",
"text": "Estrogen receptors ER",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "ihc-strong",
"display": "Strong (+++)"
}
}
]
},
{
"linkId": "ihc-er-percent",
"text": "ER expression in nuclei (%)",
"answer": [
{
"valueQuantity": {
"value": 90,
"unit": "%",
"system": "http://unitsofmeasure.org",
"code": "%"
}
}
]
},
{
"linkId": "ihc-pr-status",
"text": "Progesterone receptors PR",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "ihc-moderate",
"display": "Moderate (++)"
}
}
]
},
{
"linkId": "ihc-pr-percent",
"text": "PR expression in nuclei (%)",
"answer": [
{
"valueQuantity": {
"value": 60,
"unit": "%",
"system": "http://unitsofmeasure.org",
"code": "%"
}
}
]
},
{
"linkId": "ihc-her2-status",
"text": "HER2 status",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "her2-borderline",
"display": "HER2: expression borderline (2+)"
}
}
]
},
{
"linkId": "ihc-her2-evaluation",
"text": "HER2 evaluation",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "her2-eval-2",
"display": "HER2 evaluation: 2+"
}
}
]
},
{
"linkId": "ihc-ki67",
"text": "Ki67 proliferation index (%)",
"answer": [
{
"valueQuantity": {
"value": 25,
"unit": "%",
"system": "http://unitsofmeasure.org",
"code": "%"
}
}
]
}
]
},
{
"linkId": "grp-molecular",
"text": "Molecular studies",
"item": [
{
"linkId": "fish-result",
"text": "FISH result",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "fish-not-evaluated",
"display": "FISH: not to be evaluated"
}
}
]
},
{
"linkId": "fish-her2-average",
"text": "HER2 average"
},
{
"linkId": "fish-cep17-average",
"text": "Average CEP17"
},
{
"linkId": "fish-her2-cep17-ratio",
"text": "HER2/CEP17 ratio"
},
{
"linkId": "cish-sish-result",
"text": "CISH/SISH result",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "cish-not-evaluated",
"display": "CISH/SISH: not to be evaluated"
}
}
]
}
]
},
{
"linkId": "grp-conclusion",
"text": "Conclusion",
"item": [
{
"linkId": "conclusion-who-diagnosis",
"text": "WHO Classification diagnosis",
"answer": [
{
"valueString": "Invasive breast carcinoma of no special type (NST) (ICD-O 8500/3)"
}
]
},
{
"linkId": "conclusion-tumour-grade",
"text": "Tumour grade",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "grade-g2",
"display": "G2 (moderately differentiated)"
}
}
]
},
{
"linkId": "conclusion-tumour-size",
"text": "Tumour size (mm)",
"answer": [
{
"valueQuantity": {
"value": 18,
"unit": "mm",
"system": "http://unitsofmeasure.org",
"code": "mm"
}
}
]
},
{
"linkId": "conclusion-lvi",
"text": "Lymphovascular invasion",
"answer": [
{
"valueCoding": {
"system": "https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options",
"code": "lvi-0",
"display": "pLVI-0: not detected"
}
}
]
}
]
}
]
}