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

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: Pathologiebericht Stanzbiopsie Mamma - JSON Representation

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{
  "resourceType" : "DiagnosticReport",
  "id" : "CoreNeedleBiopsyReport",
  "meta" : {
    "profile" : [
      🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2026.0.0"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport CoreNeedleBiopsyReport</b></p><a name=\"CoreNeedleBiopsyReport\"> </a><a name=\"hcCoreNeedleBiopsyReport\"> </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>2025-01-17 15:00:00+0100</td></tr><tr><td>Reported</td><td>2025-01-17 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_105</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-CoreNeedleBiopsyMacroscopicGrouper.html\"><span title=\"Codes:{http://loinc.org 22634-0}\">Pathology report gross observation Narrative</span></a> (<span title=\"Codes:{http://snomed.info/sct 110502005}\">Structure of lower outer quadrant of left breast (body structure)</span>)</td><td/><td>Final</td><td>2025-01-16 08:30:00+0100</td></tr><tr><td><a href=\"Observation-CoreNeedleBiopsyDiagnosticConclusionGrouper.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td/><td>Final</td><td>2025-01-17</td></tr></table><p>Invasives Mammakarzinom NST (ICD-O 8500/3), Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). ER+ (85%), PR+ (50%), HER2- (nicht amplifiziert), Ki-67 10%. B-Klassifikation B5b.</p></div>"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "ACSN",
            "display" : "Accession ID"
          }
        ]
      },
      "system" : "https://pathologie.example-hospital.de/fhir/fn/befundbericht",
      "value" : "E_25_105"
    }
  ],
  "basedOn" : [
    {
      🔗 "reference" : "ServiceRequest/CoreNeedleBiopsyReportRequest"
    }
  ],
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "SP",
          "display" : "Surgical Pathology"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "60568-3",
        "display" : "Pathology Synoptic report"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/Patient4"
  },
  "effectiveDateTime" : "2025-01-17T15:00:00+01:00",
  "issued" : "2025-01-17T17:00:00+01:00",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/PathologistPractitioner"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenPart"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenBlock01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHE01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHE02"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHE03"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHE04"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideER01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideER02"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlidePR01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlidePR02"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHER2-01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideHER2-02"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideKi67-01"
    },
    {
      🔗 "reference" : "Specimen/CoreNeedleBiopsySpecimenSlideKi67-02"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/CoreNeedleBiopsyMacroscopicGrouper"
    },
    {
      🔗 "reference" : "Observation/CoreNeedleBiopsyDiagnosticConclusionGrouper"
    }
  ],
  "conclusion" : "Invasives Mammakarzinom NST (ICD-O 8500/3), Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). ER+ (85%), PR+ (50%), HER2- (nicht amplifiziert), Ki-67 10%. B-Klassifikation B5b."
}