identifier: Placer Identifier/PATH-RPT-2025-210

status: Completed

intent: Order

category: Pathology consultation, comprehensive, records and specimen with report (procedure)

code: Pathology synoptic report

subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)

encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_210; status = finished; class = IMP (IMP)

requester: Practitioner Thomas Richter

performer: Practitioner Elisabeth Hoffmann

reasonCode: Malignant neoplasm of breast (disorder)

supportingInfo:

• Condition Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
• Diagnostic Report for 'MG Breast Screening' for '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
• Observation Personal history of primary malignant neoplasm of breast (situation)
• Observation Cancer treatment --preoperative
• Observation Lesion size, largest dimension (observable entity)
• Observation Insertion of marker into breast using X-ray guidance (procedure)
• Observation 80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent|
• Observation Diathesis, function (observable entity)
• Observation Quadrant Breast
• Observation Radial position in breast [Angle] in Breast cancer specimen
• Observation Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity)
• Observation Screening interpretation (observable entity)

specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ.