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Narrative

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Source1

{
  "resourceType": "DiagnosticReport",
  "id": "Pathology-Report-2-Smalhart",
  "meta": {
    "tag": [
      {
        "code": "0388",
        "system": "urn:oid:2.16.840.1.113883.2.4.6.7",
        "display": "Medisch specialisten, pathologische anatomie"
      }
    ],
    "profile": [
      "http://medmij.nl/fhir/StructureDefinition/path-Report"
    ]
  },
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "code": "108257001",
          "system": "http://snomed.info/sct",
          "display": "pathologisch-anatomische verrichting"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "code": "252416005",
        "system": "http://snomed.info/sct",
        "display": "Histopathology test"
      }
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "system": "urn:oid:2.16.840.1.113883.2.4.3.23.3.23.1",
      "value": "T24-61237"
    }
  ],
  "basedOn": [
    {
      "reference": "ServiceRequest/Pathology-Request-2-Smalhart",
      "display": "Request for Histopathology test"
    }
  ],
  "subject": {
    "reference": "Patient/Pathology-Patient-Smalhart",
    "display": "G. Smalhart"
  },
  "effectivePeriod": {
    "start": "2023-11-01",
    "end": "2024-04-09"
  },
  "resultsInterpreter": [
    {
      "reference": "PractitionerRole/Pathology-PractitionerRole-Beuker",
      "display": "Albus Beuker, MUMC, patholoog"
    }
  ],
  "specimen": [
    {
      "reference": "Specimen/Pathology-Specimen-2-Smalhart",
      "display": "Appendix Resectie"
    }
  ],
  "result": [
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-1",
      "display": "Type tumor"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-2",
      "display": "Max diameter tumor"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-3",
      "display": "Perforatie"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-4",
      "display": "inflammatoire morfologie"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-5",
      "display": "afsterving"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-6",
      "display": "status van invasie van tumor in bloedvat"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-7",
      "display": "Dichtstbijzijnde snijvlak"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-8",
      "display": "Diepste tumordoorgroei"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-9",
      "display": "Diepste tumordoorgroei"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-10",
      "display": "status van ingroei van tumor rondom zenuw"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-11",
      "display": "Differentiatiegraad"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-2-12",
      "display": "histologisch kenmerk van tumor"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-ClinicalInformation-2",
      "display": "Klinische gegevens"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-Macroscopy-2",
      "display": "Macroscopie"
    },
    {
      "reference": "Observation/Pathology-Observation-Smalhart-Microscopy-2",
      "display": "Microscopie"
    }
  ],
  "conclusion": "<div>Appendectomie: goed / matig gedifferentieerd adenocarcinoom.</div><div>Diepste tumordoorgroei: invasie beperkt tot lamina propria / mucosa; dichtstbijzijnde snijvlak niet vrij.</div><div>Angio-invasie: niet aangetroffen; Perineurale groei: niet aangetroffen.</div><div>TNM classificatie Appendix (8e editie UICC): pTis.</div><div><br/> DIT IS EEN GEWIJZIGDE CONCLUSIE (09-04-2024).</div><div>II.</div><div>Graad 3.</div><div><br/> Conclusie 1916</div>"
}