FHIR IG analytics

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Narrative

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Source1

{
  "resourceType": "Composition",
  "id": "composition-pathology-example",
  "meta": {
    "profile": [
      "https://hl7.lt/fhir/lab/StructureDefinition/pathology-composition-lt-lab"
    ]
  },
  "language": "en",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "system": "http://hospital.lt/sid/composition-number",
      "value": "4540-baab-7a5d0877428f-93468-45y72547"
    }
  ],
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "371528001",
        "display": "Pathology report (record artifact)"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "26436-6",
          "display": "Laboratory Studies (set)"
        }
      ]
    }
  ],
  "subject": [
    {
      "reference": "Patient/patient-example"
    }
  ],
  "date": "2022-10-25T14:30:00+01:00",
  "author": [
    {
      "reference": "Practitioner/practitioner-example"
    }
  ],
  "title": "Histological examination of the breast tissue",
  "attester": [
    {
      "mode": {
        "coding": [
          {
            "code": "legal"
          }
        ]
      },
      "time": "2022-10-25T14:30:00+01:00",
      "party": {
        "reference": "Organization/organization-example"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/organization-example"
  },
  "section": [
    {
      "title": "Pre-Analytic (Clinical Context)",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "22636-5",
            "display": "Pathology report relevant history Narrative"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Information collected before laboratory processing: pathology service requests (breast histopathology and prostate pathway), the biopsy procedure, and submitted breast specimens that identify what entered the laboratory.</p></div>"
      },
      "section": [
        {
          "title": "Breast histopathology order",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Service request for breast histopathology: ordered examination, time frame, and clinical question (e.g. suspicion of malignancy).</p></div>"
          },
          "entry": [
            {
              "reference": "ServiceRequest/servicerequest-pathology-order-example"
            }
          ]
        },
        {
          "title": "Prostate pathology order",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Service request for prostate-related pathology (e.g. screening or diagnostic follow-up) using a PathologyProcedure code.</p></div>"
          },
          "entry": [
            {
              "reference": "ServiceRequest/servicerequest-pathology-prostate-order-example"
            }
          ]
        },
        {
          "title": "Breast biopsy procedure",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Procedure performed to obtain breast tissue for histology, including timing and anatomical site.</p></div>"
          },
          "entry": [
            {
              "reference": "Procedure/procedure-breast-biopsy-example"
            }
          ]
        },
        {
          "title": "Submitted specimen — right breast",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Specimen from the right breast: identifiers and traceability from collection to the laboratory.</p></div>"
          },
          "entry": [
            {
              "reference": "Specimen/specimen-right-breast-example"
            }
          ]
        },
        {
          "title": "Submitted specimen — left breast",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Specimen from the left breast: identifiers and traceability from collection to the laboratory.</p></div>"
          },
          "entry": [
            {
              "reference": "Specimen/specimen-left-breast-example"
            }
          ]
        }
      ]
    },
    {
      "title": "Macro (Macroscopic Examination)",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "74574-5",
            "display": "Macroscopic observation [Interpretation] in Specimen Narrative"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Gross examination: dimensions and weight of tissue, whether the specimen is adequate for diagnosis, preparation of embedded blocks, and laboratory histology processing.</p></div>"
      },
      "section": [
        {
          "title": "Gross specimen measurements",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Macroscopic measurements of the specimen (largest dimension, orthogonal dimensions, weight, lymph node count when applicable).</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-specimen-measurement-example"
            }
          ]
        },
        {
          "title": "Specimen adequacy",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Assessment that the received material is satisfactory for histopathological evaluation.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-specimen-adequacy-example"
            }
          ]
        },
        {
          "title": "Paraffin tissue block",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Embedded tissue block derived from the parent specimen for sectioning and slides.</p></div>"
          },
          "entry": [
            {
              "reference": "Specimen/specimen-block-1-example"
            }
          ]
        },
        {
          "title": "Histology laboratory procedure",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Laboratory histologic processing step (e.g. preparation after grossing) on the documented date.</p></div>"
          },
          "entry": [
            {
              "reference": "Procedure/procedure-histology-example"
            }
          ]
        }
      ]
    },
    {
      "title": "Micro (Microscopic Examination)",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "660-1",
            "display": "Microscopic observation [Identifier] in Specimen by Dark field examination"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Microscopic findings: tumour pattern and extent, size on slide, and immunohistochemistry for hormone receptors and HER2 where indicated.</p></div>"
      },
      "section": [
        {
          "title": "Tumour characterisation (observable)",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Structured description of neoplasm focality, type, location, nodules, and extent.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-tumor-observable-example"
            }
          ]
        },
        {
          "title": "Tumour size (dimensions)",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Measured tumour dimensions including largest diameter and further axes.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-tumor-measurement-example"
            }
          ]
        },
        {
          "title": "Oestrogen receptor (ER) status",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Immunohistochemical assessment of oestrogen receptor expression in tissue.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-estrogen-status"
            }
          ]
        },
        {
          "title": "Progesterone receptor (PR) status",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Immunohistochemical assessment of progesterone receptor expression in tissue.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-progesterone-status"
            }
          ]
        },
        {
          "title": "HER2 receptor status",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>HER2 testing result (e.g. IHC/FISH interpretation) for treatment planning.</p></div>"
          },
          "entry": [
            {
              "reference": "Observation/observation-her2-receptor-status-example"
            }
          ]
        }
      ]
    },
    {
      "title": "Synthesis (Conclusion/Integrated Diagnosis)",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "22637-3",
            "display": "Pathology report final diagnosis Narrative"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Final integrated output: the signed diagnostic report with narrative conclusion, and—where staging applies—a structured cancer Condition with TNM and morphology.</p></div>"
      },
      "section": [
        {
          "title": "Diagnostic report (signed)",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Authoritative pathology diagnostic report linking specimens, key results, and overall conclusion for the case.</p></div>"
          },
          "entry": [
            {
              "reference": "DiagnosticReport/diagnosticreport-pathology-report-example"
            }
          ]
        },
        {
          "title": "Example: prostate cancer stage (Condition)",
          "text": {
            "status": "generated",
            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Illustrative Condition resource for prostate cancer with pathological T and clinical N/M categories and ICD-O-3 morphology—shown here as a separate example of staging structure in this implementation guide.</p></div>"
          },
          "entry": [
            {
              "reference": "Condition/condition-prostate-cancer-example"
            }
          ]
        }
      ]
    }
  ]
}