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Packagelt.hl7.fhir.cervical
Resource TypeQuestionnaireResponse
IdQuestionnaireResponse-qr-cervical-colposcopy-espbi-example.json
FHIR VersionR5

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Narrative

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


English


Generated Narrative: QuestionnaireResponse qr-cervical-colposcopy-espbi-example

Language: en

LinkIDTextDefinitionAnswerdoco
.. qr-cervical-colposcopy-espbi-exampleQuestionnaire:Questionnaire: Cervical Colposcopy ESPBI Form
... patientPatient identification
.... patient.personalCodePersonal code48501019999
.... patient.nameNameJanette
.... patient.surnameSurnamePetrauskaite
... clinicalHistoryPrevious test history
.... clinicalHistory.previousColposcopyPrevious colposcopy performedSNOMED CT: 373067005 (No (qualifier value))
.... clinicalHistory.indicationIndication (reason for colposcopy)HPV 16 positive, ASC-US cytology result
... colposcopyPerformedColposcopy procedure
.... colposcopyPerformed.performedColposcopy performedSNOMED CT: 398166005 (Performed (qualifier value))
.... colposcopyPerformed.procedureDateProcedure date2025-03-15
.... colposcopyPerformed.anesthesiaAnesthesia usedSNOMED CT: 373067005 (No (qualifier value))
... adequacyColposcopy adequacy
.... adequacy.adequateAdequacy of colposcopySNOMED CT: 398166005 (Performed (qualifier value))
... swedeScoreSwede score (0-10)
.... swedeScore.acetoWhiteReactionAcetowhite reaction (0-2)1
.... swedeScore.marginsAndSurfaceMargins and surface (0-2)0
.... swedeScore.vesselsVessels (0-2)1
.... swedeScore.lesionSizeLesion size (0-2)1
.... swedeScore.iodineStainingIodine staining (0-2)0
.... swedeScore.totalScoreTotal Swede score (0-10)3
... riskRisk assessment based on Swede score
.... risk.riskLevelRisk levelSNOMED CT: 723505004 (Low risk (qualifier value))
... biopsyProcedureBiopsy procedure
.... biopsyProcedure.biopsyPerformedBiopsy performedSNOMED CT: 373066001 (Yes (qualifier value))
.... biopsyProcedure.procedureTypeBiopsy procedure typeSNOMED CT: 51675008 (Punch biopsy of cervix (procedure))
... biopsySiteBiopsy site
.... biopsySite.siteBiopsy siteSNOMED CT: 127900007 (Left superior quadrant of uterine cervix)
.... biopsySite.notesNotesAcetowhite area at 10 o'clock position, approximately 5 mm
... impressionColposcopic impression
.... impression.impressionColposcopic impressionMinor acetowhite changes in the transformation zone at 10 o'clock. No atypical vessels. Transformation zone type 1.
.... impression.recommendationRecommendationAwait biopsy result. Follow-up in 6 months with HPV co-testing.
... signaturesSignatures
.... signatures.examinerNameExaminer nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examinerPressNumberExaminer press numberLT-GYN-2024-0042
.... signatures.examDateExamination date2025-03-15T10:30:00+02:00

doco Documentation for this format

Lithuanian


Generated Narrative: QuestionnaireResponse qr-cervical-colposcopy-espbi-example

Language: en

LinkIDTextDefinitionAnswerdoco
.. qr-cervical-colposcopy-espbi-exampleQuestionnaire:Questionnaire: Cervical Colposcopy ESPBI Form
... patientPatient identification
.... patient.personalCodePersonal code48501019999
.... patient.nameNameJanette
.... patient.surnameSurnamePetrauskaite
... clinicalHistoryPrevious test history
.... clinicalHistory.previousColposcopyPrevious colposcopy performedSNOMED CT: 373067005 (No (qualifier value))
.... clinicalHistory.indicationIndication (reason for colposcopy)HPV 16 positive, ASC-US cytology result
... colposcopyPerformedColposcopy procedure
.... colposcopyPerformed.performedColposcopy performedSNOMED CT: 398166005 (Performed (qualifier value))
.... colposcopyPerformed.procedureDateProcedure date2025-03-15
.... colposcopyPerformed.anesthesiaAnesthesia usedSNOMED CT: 373067005 (No (qualifier value))
... adequacyColposcopy adequacy
.... adequacy.adequateAdequacy of colposcopySNOMED CT: 398166005 (Performed (qualifier value))
... swedeScoreSwede score (0-10)
.... swedeScore.acetoWhiteReactionAcetowhite reaction (0-2)1
.... swedeScore.marginsAndSurfaceMargins and surface (0-2)0
.... swedeScore.vesselsVessels (0-2)1
.... swedeScore.lesionSizeLesion size (0-2)1
.... swedeScore.iodineStainingIodine staining (0-2)0
.... swedeScore.totalScoreTotal Swede score (0-10)3
... riskRisk assessment based on Swede score
.... risk.riskLevelRisk levelSNOMED CT: 723505004 (Low risk (qualifier value))
... biopsyProcedureBiopsy procedure
.... biopsyProcedure.biopsyPerformedBiopsy performedSNOMED CT: 373066001 (Yes (qualifier value))
.... biopsyProcedure.procedureTypeBiopsy procedure typeSNOMED CT: 51675008 (Punch biopsy of cervix (procedure))
... biopsySiteBiopsy site
.... biopsySite.siteBiopsy siteSNOMED CT: 127900007 (Left superior quadrant of uterine cervix)
.... biopsySite.notesNotesAcetowhite area at 10 o'clock position, approximately 5 mm
... impressionColposcopic impression
.... impression.impressionColposcopic impressionMinor acetowhite changes in the transformation zone at 10 o'clock. No atypical vessels. Transformation zone type 1.
.... impression.recommendationRecommendationAwait biopsy result. Follow-up in 6 months with HPV co-testing.
... signaturesSignatures
.... signatures.examinerNameExaminer nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examinerPressNumberExaminer press numberLT-GYN-2024-0042
.... signatures.examDateExamination date2025-03-15T10:30:00+02:00

doco Documentation for this format

Source1

{
  "resourceType": "QuestionnaireResponse",
  "id": "qr-cervical-colposcopy-espbi-example",
  "language": "en",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "questionnaire": "https://hl7.lt/fhir/cervical/Questionnaire/questionnaire-cervical-colposcopy-espbi",
  "status": "completed",
  "subject": {
    "reference": "Patient/patient-female-example"
  },
  "authored": "2025-03-15T10:30:00+02:00",
  "author": {
    "reference": "Practitioner/practitioner-example"
  },
  "item": [
    {
      "linkId": "patient",
      "text": "Patient identification",
      "item": [
        {
          "linkId": "patient.personalCode",
          "text": "Personal code",
          "answer": [
            {
              "valueString": "48501019999"
            }
          ]
        },
        {
          "linkId": "patient.name",
          "text": "Name",
          "answer": [
            {
              "valueString": "Janette"
            }
          ]
        },
        {
          "linkId": "patient.surname",
          "text": "Surname",
          "answer": [
            {
              "valueString": "Petrauskaite"
            }
          ]
        }
      ]
    },
    {
      "linkId": "clinicalHistory",
      "text": "Previous test history",
      "item": [
        {
          "linkId": "clinicalHistory.previousColposcopy",
          "text": "Previous colposcopy performed",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373067005",
                "display": "No (qualifier value)"
              }
            }
          ]
        },
        {
          "linkId": "clinicalHistory.indication",
          "text": "Indication (reason for colposcopy)",
          "answer": [
            {
              "valueString": "HPV 16 positive, ASC-US cytology result"
            }
          ]
        }
      ]
    },
    {
      "linkId": "colposcopyPerformed",
      "text": "Colposcopy procedure",
      "item": [
        {
          "linkId": "colposcopyPerformed.performed",
          "text": "Colposcopy performed",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "398166005",
                "display": "Performed (qualifier value)"
              }
            }
          ]
        },
        {
          "linkId": "colposcopyPerformed.procedureDate",
          "text": "Procedure date",
          "answer": [
            {
              "valueDate": "2025-03-15"
            }
          ]
        },
        {
          "linkId": "colposcopyPerformed.anesthesia",
          "text": "Anesthesia used",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373067005",
                "display": "No (qualifier value)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "adequacy",
      "text": "Colposcopy adequacy",
      "item": [
        {
          "linkId": "adequacy.adequate",
          "text": "Adequacy of colposcopy",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "398166005",
                "display": "Performed (qualifier value)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "swedeScore",
      "text": "Swede score (0-10)",
      "item": [
        {
          "linkId": "swedeScore.acetoWhiteReaction",
          "text": "Acetowhite reaction (0-2)",
          "answer": [
            {
              "valueInteger": 1
            }
          ]
        },
        {
          "linkId": "swedeScore.marginsAndSurface",
          "text": "Margins and surface (0-2)",
          "answer": [
            {
              "valueInteger": 0
            }
          ]
        },
        {
          "linkId": "swedeScore.vessels",
          "text": "Vessels (0-2)",
          "answer": [
            {
              "valueInteger": 1
            }
          ]
        },
        {
          "linkId": "swedeScore.lesionSize",
          "text": "Lesion size (0-2)",
          "answer": [
            {
              "valueInteger": 1
            }
          ]
        },
        {
          "linkId": "swedeScore.iodineStaining",
          "text": "Iodine staining (0-2)",
          "answer": [
            {
              "valueInteger": 0
            }
          ]
        },
        {
          "linkId": "swedeScore.totalScore",
          "text": "Total Swede score (0-10)",
          "answer": [
            {
              "valueInteger": 3
            }
          ]
        }
      ]
    },
    {
      "linkId": "risk",
      "text": "Risk assessment based on Swede score",
      "item": [
        {
          "linkId": "risk.riskLevel",
          "text": "Risk level",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "723505004",
                "display": "Low risk (qualifier value)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "biopsyProcedure",
      "text": "Biopsy procedure",
      "item": [
        {
          "linkId": "biopsyProcedure.biopsyPerformed",
          "text": "Biopsy performed",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes (qualifier value)"
              }
            }
          ]
        },
        {
          "linkId": "biopsyProcedure.procedureType",
          "text": "Biopsy procedure type",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "51675008",
                "display": "Punch biopsy of cervix (procedure)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "biopsySite",
      "text": "Biopsy site",
      "item": [
        {
          "linkId": "biopsySite.site",
          "text": "Biopsy site",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "127900007",
                "display": "Left superior quadrant of uterine cervix"
              }
            }
          ]
        },
        {
          "linkId": "biopsySite.notes",
          "text": "Notes",
          "answer": [
            {
              "valueString": "Acetowhite area at 10 o'clock position, approximately 5 mm"
            }
          ]
        }
      ]
    },
    {
      "linkId": "impression",
      "text": "Colposcopic impression",
      "item": [
        {
          "linkId": "impression.impression",
          "text": "Colposcopic impression",
          "answer": [
            {
              "valueString": "Minor acetowhite changes in the transformation zone at 10 o'clock. No atypical vessels. Transformation zone type 1."
            }
          ]
        },
        {
          "linkId": "impression.recommendation",
          "text": "Recommendation",
          "answer": [
            {
              "valueString": "Await biopsy result. Follow-up in 6 months with HPV co-testing."
            }
          ]
        }
      ]
    },
    {
      "linkId": "signatures",
      "text": "Signatures",
      "item": [
        {
          "linkId": "signatures.examinerName",
          "text": "Examiner name",
          "answer": [
            {
              "valueString": "Jonas"
            }
          ]
        },
        {
          "linkId": "signatures.examinerSurname",
          "text": "Examiner surname",
          "answer": [
            {
              "valueString": "Kazlauskas"
            }
          ]
        },
        {
          "linkId": "signatures.examinerPressNumber",
          "text": "Examiner press number",
          "answer": [
            {
              "valueString": "LT-GYN-2024-0042"
            }
          ]
        },
        {
          "linkId": "signatures.examDate",
          "text": "Examination date",
          "answer": [
            {
              "valueDateTime": "2025-03-15T10:30:00+02:00"
            }
          ]
        }
      ]
    }
  ]
}