Breast Cancer Specification - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

• Narrative Content
• XML
• JSON
• TTL

: Pathologiebericht BET Mamma - XML Representation

Raw xml | Download

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="BreastResectionReport"/>
  <meta>
    <profile
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2026.0.0"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: DiagnosticReport BreastResectionReport</b></p><a name="BreastResectionReport"> </a><a name="hcBreastResectionReport"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="https://simplifier.net/resolve?scope=de.medizininformatikinitiative.kerndatensatz.patho@2026.0.0&amp;canonical=https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report">MII PR Patho Report</a> version: 2026.0.0</p></div><h2><span title="Codes:{http://loinc.org 60568-3}">Pathology Synoptic report</span> (<span title="Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 SP}">Surgical Pathology</span>) </h2><table class="grid"><tr><td>Subject</td><td>Sabine Becker  Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)</td></tr><tr><td>When For</td><td>2025-02-10 14:00:00+0100</td></tr><tr><td>Reported</td><td>2025-02-10 17:00:00+0100</td></tr><tr><td>Performer</td><td> <a href="Practitioner-PathologistPractitioner.html">Practitioner Elisabeth Hoffmann </a></td></tr><tr><td>Identifier</td><td> Accession ID/E_25_210</td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-BreastResectionMacroscopicGrouper.html"><span title="Codes:{http://loinc.org 22634-0}">Pathology report gross observation Narrative</span></a> (<span title="Codes:{http://snomed.info/sct 76752008}">Breast structure (body structure)</span>)</td><td/><td>Final</td><td>2025-02-06 08:30:00+0100</td></tr><tr><td><a href="Observation-BreastResectionDiagnosticConclusionGrouper.html"><span title="Codes:{http://loinc.org 22637-3}">Pathology report final diagnosis Narrative</span></a></td><td/><td>Final</td><td>2025-02-10</td></tr></table><p>Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c, Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). Begleitendes DCIS, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen. Alle Resektionsränder tumorfrei (invasiv 5 mm, DCIS 3 mm). Keine LVI. ER+ (90%), PR+ (60%), HER2 1+ (nicht amplifiziert), Ki-67 15%.</p></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
      </coding>
    </type>
    <system
            value="https://pathologie.example-hospital.de/fhir/fn/befundbericht"/>
    <value value="E_25_210"/>
  </identifier>
  <basedOn>🔗 
    <reference value="ServiceRequest/BreastResectionReportRequest"/>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="SP"/>
      <display value="Surgical Pathology"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="60568-3"/>
      <display value="Pathology Synoptic report"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/Patient4"/>
  </subject>
  <effectiveDateTime value="2025-02-10T14:00:00+01:00"/>
  <issued value="2025-02-10T17:00:00+01:00"/>
  <performer>🔗 
    <reference value="Practitioner/PathologistPractitioner"/>
  </performer>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenPart"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock02"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock03"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock04"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock05"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenBlock06"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideHE01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideHE02"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideER01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlidePR01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideHER2IHC01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideKi67-01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideCK18-01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlidep40-01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideECad-01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideBlock02-HE01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideBlock02-HE02"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideRR-Superior-HE01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideRR-Inferior-HE01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideRR-Medial-HE01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/BreastResectionSpecimenSlideRR-Lateral-HE01"/>
  </specimen>
  <result>🔗 
    <reference value="Observation/BreastResectionMacroscopicGrouper"/>
  </result>
  <result>🔗 
    <reference
               value="Observation/BreastResectionDiagnosticConclusionGrouper"/>
  </result>
  <conclusion
              value="Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c, Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). Begleitendes DCIS, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen. Alle Resektionsränder tumorfrei (invasiv 5 mm, DCIS 3 mm). Keine LVI. ER+ (90%), PR+ (60%), HER2 1+ (nicht amplifiziert), Ki-67 15%."/>
</DiagnosticReport>