FHIR IG analytics| Package | lt.hl7.fhir.cervical |
| Resource Type | QuestionnaireResponse |
| Id | QuestionnaireResponse-qr-cervical-histology-espbi-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 qr-cervical-histology-espbi-example
Language: en
| LinkID | Text | Definition | Answer |
|---|---|---|---|
  qr-cervical-histology-espbi-example | Questionnaire:Cervical Histopathological Examination – ESPBI Form | ||
  referral | Referral to perform pathology test | ||
  referral.personalCode | Personal code | 48501019999 | |
| referral.name | Name | Janette | |
| referral.surname | Surname | Petrauskaite | |
| referral.dateOfBirth | Date of birth | 1985-01-01 | |
 referral.clinicalDiagnosis | Clinical diagnosis (ICD-10 code with name) | N87.1 Moderate cervical dysplasia | |
| previousProcedures | Previous procedures history | ||
| previousProcedures.hasPreviousProcedure | Has previous procedure | SNOMED CT: 373066001 (Yes (qualifier value)) | |
| previousProcedures.procedureType | Type of previous procedure | SNOMED CT: 50796003 (Cervical biopsy (procedure)) | |
| previousProcedures.procedureDate | Procedure date | 2024-11-20 | |
| colposcopyData | Colposcopy examination data | ||
| colposcopyData.colposcopyStatus | Colposcopy status | SNOMED CT: 392003006 (Colposcopy performed) | |
| colposcopyData.swedeScore | Swede score (0-10) | 7 | |
| colposcopyData.adequacy | Adequacy of colposcopy | SNOMED CT: 125152006 (Specimen satisfactory for evaluation (finding)) | |
| biopsyProcedure | Nature of operation/procedure | ||
| biopsyProcedure.procedureType | Procedure type | SNOMED CT: 54535009 (Cone biopsy of cervix (procedure)) | |
| biopsySites | Biopsy site description | ||
| biopsySites.containers | Container | ||
 biopsySites.containers.biopsySite | Biopsy site | SNOMED CT: 127900007 (Structure of left superior quadrant of uterine cervix) | |
| biopsySites.containers.anatomicalNotes | Anatomical notes | Cone biopsy specimen from transformation zone, left superior quadrant | |
| biopsySites.containers.numberOfFragments | Number of fragments | 1 | |
| macroscopic | Macroscopic examination | ||
| macroscopic.tissueSizeX | Tissue size X (mm) | 18 | |
| macroscopic.tissueSizeY | Tissue size Y (mm) | 15 | |
| macroscopic.tissueSizeZ | Tissue size Z (mm) | 12 | |
| macroscopic.ectocervixSizeX | Ectocervix size X (mm) | 16 | |
| macroscopic.ectocervixSizeY | Ectocervix size Y (mm) | 14 | |
| macroscopic.notes | Notes | Cone biopsy specimen, grey-white tissue, well-oriented with ink marking at 12 o'clock position | |
| microscopic | Microscopic examination | ||
| microscopic.description | Microscopic description | Sections show high-grade squamous intraepithelial neoplasia (CIN2) involving the transformation zone. The dysplastic epithelium extends through the upper two-thirds of the squamous epithelium with increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and mitotic figures. No stromal invasion identified. Endocervical glands are unremarkable. | |
| conclusion | Conclusion / Diagnosis | ||
| conclusion.diagnosisCategory | Diagnosis category | SNOMED CT: 400049009 (Squamous intraepithelial neoplasia grade 2 (morphologic abnormality)) | |
| grade | Histological grade | ||
| grade.grade | Grade | SNOMED CT: 1228850007 (American Joint Committee on Cancer grade G2 (qualifier value)) | |
| pLVI | Lymphovascular invasion (pLVI) | ||
| pLVI.status | pLVI status | SNOMED CT: 373067005 (No (qualifier value)) | |
| margins | Surgical margins | ||
| margins.marginStatus | Margin status | SNOMED CT: 310342002 (Excision - clear margin (finding)) | |
| tnm | TNM staging | ||
| tnm.pT | pT stage | SNOMED CT: 1228953005 (American Joint Committee on Cancer pTis (qualifier value)) | |
| tnm.pR | pR stage | SNOMED CT: 1222638005 (American Joint Committee on Cancer R0 (qualifier value)) | |
| tnm.icd10Code | ICD-10 code | D06.9 | |
| tnm.snomedCode | SNOMED CT code | 400049009 | |
| conductedBy | Conducted by | ||
| conductedBy.conductedName | Name | Petras | |
| conductedBy.conductedSurname | Surname | Kazlauskas | |
| conductedBy.conductedPressNumber | Medical press number | MED-LT-54321 | |
| conductedBy.responseDate | Response date | 2025-04-15T14:30:00+03:00 | |
| confirmedBy | Confirmed by | ||
| confirmedBy.confirmedName | Name | Ruta | |
| confirmedBy.confirmedSurname | Surname | Jonaite | |
| confirmedBy.confirmedPressNumber | Medical press number | MED-LT-67890 | |
| confirmedBy.confirmationDate | Confirmation date | 2025-04-16T09:00:00+03:00 | |
| Documentation for this format | |||
Lithuanian
Generated Narrative: QuestionnaireResponse qr-cervical-histology-espbi-example
Language: en
| LinkID | Text | Definition | Answer |
|---|---|---|---|
| qr-cervical-histology-espbi-example | Questionnaire:Cervical Histopathological Examination – ESPBI Form | ||
| referral | Referral to perform pathology test | ||
| referral.personalCode | Personal code | 48501019999 | |
| referral.name | Name | Janette | |
| referral.surname | Surname | Petrauskaite | |
| referral.dateOfBirth | Date of birth | 1985-01-01 | |
| referral.clinicalDiagnosis | Clinical diagnosis (ICD-10 code with name) | N87.1 Moderate cervical dysplasia | |
| previousProcedures | Previous procedures history | ||
| previousProcedures.hasPreviousProcedure | Has previous procedure | SNOMED CT: 373066001 (Yes (qualifier value)) | |
| previousProcedures.procedureType | Type of previous procedure | SNOMED CT: 50796003 (Cervical biopsy (procedure)) | |
| previousProcedures.procedureDate | Procedure date | 2024-11-20 | |
| colposcopyData | Colposcopy examination data | ||
| colposcopyData.colposcopyStatus | Colposcopy status | SNOMED CT: 392003006 (Colposcopy performed) | |
| colposcopyData.swedeScore | Swede score (0-10) | 7 | |
| colposcopyData.adequacy | Adequacy of colposcopy | SNOMED CT: 125152006 (Specimen satisfactory for evaluation (finding)) | |
| biopsyProcedure | Nature of operation/procedure | ||
| biopsyProcedure.procedureType | Procedure type | SNOMED CT: 54535009 (Cone biopsy of cervix (procedure)) | |
| biopsySites | Biopsy site description | ||
| biopsySites.containers | Container | ||
| biopsySites.containers.biopsySite | Biopsy site | SNOMED CT: 127900007 (Structure of left superior quadrant of uterine cervix) | |
| biopsySites.containers.anatomicalNotes | Anatomical notes | Cone biopsy specimen from transformation zone, left superior quadrant | |
| biopsySites.containers.numberOfFragments | Number of fragments | 1 | |
| macroscopic | Macroscopic examination | ||
| macroscopic.tissueSizeX | Tissue size X (mm) | 18 | |
| macroscopic.tissueSizeY | Tissue size Y (mm) | 15 | |
| macroscopic.tissueSizeZ | Tissue size Z (mm) | 12 | |
| macroscopic.ectocervixSizeX | Ectocervix size X (mm) | 16 | |
| macroscopic.ectocervixSizeY | Ectocervix size Y (mm) | 14 | |
| macroscopic.notes | Notes | Cone biopsy specimen, grey-white tissue, well-oriented with ink marking at 12 o'clock position | |
| microscopic | Microscopic examination | ||
| microscopic.description | Microscopic description | Sections show high-grade squamous intraepithelial neoplasia (CIN2) involving the transformation zone. The dysplastic epithelium extends through the upper two-thirds of the squamous epithelium with increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and mitotic figures. No stromal invasion identified. Endocervical glands are unremarkable. | |
| conclusion | Conclusion / Diagnosis | ||
| conclusion.diagnosisCategory | Diagnosis category | SNOMED CT: 400049009 (Squamous intraepithelial neoplasia grade 2 (morphologic abnormality)) | |
| grade | Histological grade | ||
| grade.grade | Grade | SNOMED CT: 1228850007 (American Joint Committee on Cancer grade G2 (qualifier value)) | |
| pLVI | Lymphovascular invasion (pLVI) | ||
| pLVI.status | pLVI status | SNOMED CT: 373067005 (No (qualifier value)) | |
| margins | Surgical margins | ||
| margins.marginStatus | Margin status | SNOMED CT: 310342002 (Excision - clear margin (finding)) | |
| tnm | TNM staging | ||
| tnm.pT | pT stage | SNOMED CT: 1228953005 (American Joint Committee on Cancer pTis (qualifier value)) | |
| tnm.pR | pR stage | SNOMED CT: 1222638005 (American Joint Committee on Cancer R0 (qualifier value)) | |
| tnm.icd10Code | ICD-10 code | D06.9 | |
| tnm.snomedCode | SNOMED CT code | 400049009 | |
| conductedBy | Conducted by | ||
| conductedBy.conductedName | Name | Petras | |
| conductedBy.conductedSurname | Surname | Kazlauskas | |
| conductedBy.conductedPressNumber | Medical press number | MED-LT-54321 | |
| conductedBy.responseDate | Response date | 2025-04-15T14:30:00+03:00 | |
| confirmedBy | Confirmed by | ||
| confirmedBy.confirmedName | Name | Ruta | |
| confirmedBy.confirmedSurname | Surname | Jonaite | |
| confirmedBy.confirmedPressNumber | Medical press number | MED-LT-67890 | |
| confirmedBy.confirmationDate | Confirmation date | 2025-04-16T09:00:00+03:00 | |
| Documentation for this format | |||
FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "qr-cervical-histology-espbi-example",
"language": "en",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"questionnaire": "https://hl7.lt/fhir/cervical/Questionnaire/questionnaire-cervical-histology-espbi",
"status": "completed",
"subject": {
"reference": "Patient/patient-female-example"
},
"authored": "2025-04-15T14:30:00+03:00",
"author": {
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},
"item": [
{
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{
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},
{
"linkId": "colposcopyData",
"text": "Colposcopy examination data",
"item": [
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"text": "Colposcopy status",
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"code": "392003006",
"display": "Colposcopy performed"
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{
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"text": "Swede score (0-10)",
"answer": [
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{
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"text": "Adequacy of colposcopy",
"answer": [
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"valueCoding": {
"system": "http://snomed.info/sct",
"code": "125152006",
"display": "Specimen satisfactory for evaluation (finding)"
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{
"linkId": "biopsyProcedure",
"text": "Nature of operation/procedure",
"item": [
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"linkId": "biopsyProcedure.procedureType",
"text": "Procedure type",
"answer": [
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{
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"text": "Biopsy site description",
"item": [
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"text": "Anatomical notes",
"answer": [
{
"valueString": "Cone biopsy specimen from transformation zone, left superior quadrant"
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]
},
{
"linkId": "biopsySites.containers.numberOfFragments",
"text": "Number of fragments",
"answer": [
{
"valueInteger": 1
}
]
}
]
}
]
},
{
"linkId": "macroscopic",
"text": "Macroscopic examination",
"item": [
{
"linkId": "macroscopic.tissueSizeX",
"text": "Tissue size X (mm)",
"answer": [
{
"valueDecimal": 18
}
]
},
{
"linkId": "macroscopic.tissueSizeY",
"text": "Tissue size Y (mm)",
"answer": [
{
"valueDecimal": 15
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},
{
"linkId": "macroscopic.tissueSizeZ",
"text": "Tissue size Z (mm)",
"answer": [
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"valueDecimal": 12
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]
},
{
"linkId": "macroscopic.ectocervixSizeX",
"text": "Ectocervix size X (mm)",
"answer": [
{
"valueDecimal": 16
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},
{
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"text": "Ectocervix size Y (mm)",
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{
"linkId": "macroscopic.notes",
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},
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{
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{
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"text": "Grade",
"answer": [
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"system": "http://snomed.info/sct",
"code": "1228850007",
"display": "American Joint Committee on Cancer grade G2 (qualifier value)"
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},
{
"linkId": "pLVI",
"text": "Lymphovascular invasion (pLVI)",
"item": [
{
"linkId": "pLVI.status",
"text": "pLVI status",
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"valueCoding": {
"system": "http://snomed.info/sct",
"code": "373067005",
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},
{
"linkId": "margins",
"text": "Surgical margins",
"item": [
{
"linkId": "margins.marginStatus",
"text": "Margin status",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "310342002",
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},
{
"linkId": "tnm",
"text": "TNM staging",
"item": [
{
"linkId": "tnm.pT",
"text": "pT stage",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "1228953005",
"display": "American Joint Committee on Cancer pTis (qualifier value)"
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}
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},
{
"linkId": "tnm.pR",
"text": "pR stage",
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"valueCoding": {
"system": "http://snomed.info/sct",
"code": "1222638005",
"display": "American Joint Committee on Cancer R0 (qualifier value)"
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{
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"text": "SNOMED CT code",
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},
{
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},
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"text": "Surname",
"answer": [
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}
]
},
{
"linkId": "conductedBy.conductedPressNumber",
"text": "Medical press number",
"answer": [
{
"valueString": "MED-LT-54321"
}
]
},
{
"linkId": "conductedBy.responseDate",
"text": "Response date",
"answer": [
{
"valueDateTime": "2025-04-15T14:30:00+03:00"
}
]
}
]
},
{
"linkId": "confirmedBy",
"text": "Confirmed by",
"item": [
{
"linkId": "confirmedBy.confirmedName",
"text": "Name",
"answer": [
{
"valueString": "Ruta"
}
]
},
{
"linkId": "confirmedBy.confirmedSurname",
"text": "Surname",
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]
},
{
"linkId": "confirmedBy.confirmedPressNumber",
"text": "Medical press number",
"answer": [
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"valueString": "MED-LT-67890"
}
]
},
{
"linkId": "confirmedBy.confirmationDate",
"text": "Confirmation date",
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"valueDateTime": "2025-04-16T09:00:00+03:00"
}
]
}
]
}
]
}