{
  "resourceType" : "Bundle",
  "id" : "TransurethralEnucleationDocument",
  "identifier" : {
    "system" : "https://pathologie.example-hospital.de/fhir/fn/befundbericht",
    "value" : "E_24_004"
  },
  "type" : "document",
  "timestamp" : "2024-04-15T08:00:00+01:00",
  "entry" : [{
    "fullUrl" : "http://prostatecancerspec.org/Composition/TransurethralEnucleationComposition",
    "resource" : {
      "resourceType" : "Composition",
      "id" : "TransurethralEnucleationComposition",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_TransurethralEnucleationComposition\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition TransurethralEnucleationComposition</b></p><a name=\"TransurethralEnucleationComposition\"> </a><a name=\"hcTransurethralEnucleationComposition\"> </a><p><b>identifier</b>: Accession ID/PATH-COMP-2024-004</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 11526-1}, {http://ihe-d.de/CodeSystems/IHEXDStypeCode PATH}\">Pathology study</span></p><p><b>encounter</b>: <a href=\"Encounter-TransurethralEnucleationEncounter.html\">Encounter: identifier = http://example.hospital.de/encounters#E_24_004; status = finished; class = IMP (IMP)</a></p><p><b>date</b>: 2024-04-15 08:00:00+0100</p><p><b>author</b>: <a href=\"Organization-PathologyLabOrganization.html\">Pathologisches Institut</a></p><p><b>title</b>: Histopathologischer Befundbericht - Prostata Enucleation</p><h3>Attesters</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td>Legal</td><td><a href=\"Organization-PathologyLabOrganization.html\">Organization Pathologielabor</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-PathologyLabOrganization.html\">Organization Pathologielabor</a></p><h3>Events</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Code</b></td><td><b>Detail</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode PATREPE}\">pathology report entry task</span></td><td><a href=\"ServiceRequest-TransurethralEnucleationReportRequest.html\">ServiceRequest Prostatectomy (procedure)</a></td></tr></table></div>"
      },
      "identifier" : {
        "type" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "ACSN",
            "display" : "Accession ID"
          }]
        },
        "system" : "http://example.hospital.de/pathology-reports",
        "value" : "PATH-COMP-2024-004"
      },
      "status" : "final",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "11526-1",
          "display" : "Pathology study"
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        {
          "system" : "http://ihe-d.de/CodeSystems/IHEXDStypeCode",
          "code" : "PATH"
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      },
      "subject" : {
        "reference" : "Patient/Patient3",
        "display" : "Klaus Becker, geb. 10.11.1958 (PAT-2024-003)"
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      "encounter" : {
        "reference" : "Encounter/TransurethralEnucleationEncounter"
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      "date" : "2024-04-15T08:00:00+01:00",
      "author" : [{
        "reference" : "Organization/PathologyLabOrganization",
        "display" : "Pathologisches Institut"
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      "title" : "Histopathologischer Befundbericht - Prostata Enucleation",
      "attester" : [{
        "mode" : "legal",
        "party" : {
          "reference" : "Organization/PathologyLabOrganization"
        }
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      "custodian" : {
        "reference" : "Organization/PathologyLabOrganization"
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      "event" : [{
        "code" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "PATREPE"
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        "detail" : [{
          "reference" : "ServiceRequest/TransurethralEnucleationReportRequest"
        }]
      }],
      "section" : [{
        "title" : "Pathologiebefundbericht",
        "code" : {
          "coding" : [{
            "system" : "http://loinc.org",
            "code" : "60567-5",
            "display" : "Comprehensive pathology report panel"
          }]
        },
        "text" : {
          "status" : "additional",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Klinische Angaben</h3><p>Obstruktive Miktionsbeschwerden. PSA 12,5 ng/ml. Prostata-Enukleation (HoLEP/ThuLEP). V.a. Prostatakarzinom.</p><h3>Makroskopie</h3><p>Enukleationspräparat 25 g, Maße 3,5 × 2,8 × 2,2 cm. Keine Samenblasen, keine Lymphknoten im Resektat.</p><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>Präparat</td><td>Prostata-Enukleationspräparat</td></tr><tr><td>Gewicht</td><td>25 g</td></tr><tr><td>Maße (L × B × T)</td><td>3,5 × 2,8 × 2,2 cm</td></tr><tr><td>Samenblasen</td><td>Nicht im Resektat</td></tr><tr><td>Lymphknoten</td><td>Nicht im Resektat</td></tr></tbody></table><h3>Mikroskopie</h3><p>Azinäres Adenokarzinom der Prostata mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration mit perineuralem und lymphovaskulärem Befall.</p><h3>Diagnostische Schlussfolgerung</h3><p>Gleason-Score 4+5=9, ISUP-Gradgruppe 5 (WHO 2016). Anteil Gleasonmuster 4/5: 90%. Tumorinfiltration ca. 60% des Prostatagewebes. Intraduktales Karzinom und invasive kribriforme Anteile nachgewiesen. Extraprostatische Ausbreitung, Samenblaseninvasion, lymphovaskuläre Invasion und perineurale Infiltration nachgewiesen.</p><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>Histologischer Typ</td><td>Azinäres Adenokarzinom mit invasiven kribriformen Anteilen (8140/3)</td></tr><tr><td>Gleason-Score</td><td>4+5=9</td></tr><tr><td>ISUP-Gradgruppe</td><td>5 (WHO 2016)</td></tr><tr><td>Tumoranteil</td><td>60%</td></tr><tr><td>Anteil Gleason 4/5</td><td>90%</td></tr><tr><td>Intraduktales Karzinom</td><td>Nachgewiesen</td></tr><tr><td>Invasives kribriformes Karzinom</td><td>Nachgewiesen</td></tr><tr><td>Extraprostatische Ausbreitung</td><td>Nachgewiesen</td></tr><tr><td>Samenblaseninfiltration</td><td>Nachgewiesen</td></tr><tr><td>Lymphovaskuläre Invasion</td><td>Nachgewiesen</td></tr><tr><td>Perineurale Infiltration</td><td>Nachgewiesen</td></tr></tbody></table><p><b>Diagnose:</b> Azinäres Adenokarzinom der Prostata (ICD-O 8140/3) – High-grade</p><p><b>Empfehlung:</b> Staging-Untersuchungen und interdisziplinäre Tumorkonferenz.</p></div>"
        },
        "entry" : [{
          "reference" : "DiagnosticReport/TransurethralEnucleationReport"
        }]
      }]
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/Patient/Patient3",
    "resource" : {
      "resourceType" : "Patient",
      "id" : "Patient3",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_Patient3\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient Patient3</b></p><a name=\"Patient3\"> </a><a name=\"hcPatient3\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</p><hr/></div>"
      },
      "identifier" : [{
        "system" : "http://example.hospital.de/patient-ids",
        "value" : "PAT-2024-003"
      }],
      "name" : [{
        "family" : "Becker",
        "given" : ["Klaus"]
      }],
      "gender" : "male",
      "birthDate" : "1958-11-10"
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/Organization/PathologyLabOrganization",
    "resource" : {
      "resourceType" : "Organization",
      "id" : "PathologyLabOrganization",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_PathologyLabOrganization\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization PathologyLabOrganization</b></p><a name=\"PathologyLabOrganization\"> </a><a name=\"hcPathologyLabOrganization\"> </a><p><b>identifier</b>: <code>http://example.hospital.de/organization-ids</code>/ORG-PATH-001</p><p><b>name</b>: Pathologielabor</p></div>"
      },
      "identifier" : [{
        "system" : "http://example.hospital.de/organization-ids",
        "value" : "ORG-PATH-001"
      }],
      "name" : "Pathologielabor"
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/DiagnosticReport/TransurethralEnucleationReport",
    "resource" : {
      "resourceType" : "DiagnosticReport",
      "id" : "TransurethralEnucleationReport",
      "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\"><a name=\"DiagnosticReport_TransurethralEnucleationReport\"> </a><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport TransurethralEnucleationReport</b></p><a name=\"TransurethralEnucleationReport\"> </a><a name=\"hcTransurethralEnucleationReport\"> </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>Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</td></tr><tr><td>Relevant Time</td><td>2024-05-12 17:00:00+0100</td></tr><tr><td>Reported</td><td>2024-05-13 08:00:00+0100</td></tr><tr><td>Performer</td><td> <a href=\"Practitioner-PathologistPractitioner.html\">Practitioner Maria Schneider </a></td></tr><tr><td>Identifier</td><td> Accession ID/E_24_004</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>Relevant Time</b></td></tr><tr><td><a href=\"Observation-TransurethralEnucleationMacroscopicGrouper.html\"><span title=\"Codes:{http://loinc.org 22634-0}\">Pathology report gross observation Narrative</span></a> (<span title=\"Codes:{http://snomed.info/sct 41216001}\">Prostate</span>)</td><td/><td>Final</td><td>2024-04-11 14:00:00+0100</td></tr><tr><td><a href=\"Observation-TransurethralEnucleationDiagnosticConclusionGrouper.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td/><td>Final</td><td>2024-05-12</td></tr></table><p>Prostata Enucleation: Azinäres Adenokarzinom, Gleason Score 4+5=9 (ISUP Grade Group 5), mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration (60% des Gewebes) mit extraprostatischer Extension, Samenblaseninvasion, perineuralem und lymphovaskulärem Befall.</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_24_004"
      }],
      "basedOn" : [{
        "reference" : "ServiceRequest/TransurethralEnucleationReportRequest"
      }],
      "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/Patient3"
      },
      "effectiveDateTime" : "2024-05-12T17:00:00+01:00",
      "issued" : "2024-05-13T08:00:00+01:00",
      "performer" : [{
        "reference" : "Practitioner/PathologistPractitioner"
      }],
      "specimen" : [{
        "reference" : "Specimen/TransurethralEnucleationSpecimenPart"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenBlock01"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide01A"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide01B"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenBlock02"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide02A"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide02B"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenBlock03"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide03A"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide03B"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenBlock04"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide04A"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide04B"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenBlock05"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide05A"
      },
      {
        "reference" : "Specimen/TransurethralEnucleationSpecimenSlide05B"
      }],
      "result" : [{
        "reference" : "Observation/TransurethralEnucleationMacroscopicGrouper"
      },
      {
        "reference" : "Observation/TransurethralEnucleationDiagnosticConclusionGrouper"
      }],
      "conclusion" : "Prostata Enucleation: Azinäres Adenokarzinom, Gleason Score 4+5=9 (ISUP Grade Group 5), mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration (60% des Gewebes) mit extraprostatischer Extension, Samenblaseninvasion, perineuralem und lymphovaskulärem Befall."
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/Observation/TransurethralEnucleationDiagnosticConclusionGrouper",
    "resource" : {
      "resourceType" : "Observation",
      "id" : "TransurethralEnucleationDiagnosticConclusionGrouper",
      "meta" : {
        "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-diagnostic-conclusion-grouper|2026.0.0"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_TransurethralEnucleationDiagnosticConclusionGrouper\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation TransurethralEnucleationDiagnosticConclusionGrouper</b></p><a name=\"TransurethralEnucleationDiagnosticConclusionGrouper\"> </a><a name=\"hcTransurethralEnucleationDiagnosticConclusionGrouper\"> </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-diagnostic-conclusion-grouper\">MII PR Patho Diagnostic Conclusion Grouper</a> version: 2026.0.0</p></div><p><b>basedOn</b>: <a href=\"ServiceRequest-TransurethralEnucleationReportRequest.html\">ServiceRequest Prostatectomy (procedure)</a></p><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></p><p><b>subject</b>: <a href=\"Patient-Patient3.html\">Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</a></p><p><b>effective</b>: 2024-05-12</p><p><b>performer</b>: <a href=\"Practitioner-PathologistPractitioner.html\">Practitioner Maria Schneider </a></p><p><b>hasMember</b>: </p><ul><li><a href=\"Observation-TransurethralEnucleationHistologicalTypeICDO3.html\">Observation Histology and Behavior ICD-O-3 Cancer</a></li><li><a href=\"Observation-TransurethralEnucleationMorphologyFreeText.html\">Observation Histology type in Cancer specimen Narrative</a></li><li><a href=\"Observation-TransurethralEnucleationPrimaryGleasonPattern.html\">Observation Gleason pattern.primary in Prostate tumor</a></li><li><a href=\"Observation-TransurethralEnucleationSecondaryGleasonPattern.html\">Observation Gleason pattern.secondary in Prostate tumor</a></li><li><a href=\"Observation-TransurethralEnucleationGleasonScoreTotal.html\">Observation Gleason score in Specimen Qualitative</a></li><li><a href=\"Observation-TransurethralEnucleationPercentageGleason45.html\">Observation Prostate tumor area with Gleason pattern 4+5/Total tumor area [Area Fraction] in Prostate tumor by Microscopy</a></li><li><a href=\"Observation-TransurethralEnucleationGradingGroupISUP.html\">Observation Histologic grade of primary malignant neoplasm of prostate by International Society of Urological Pathology technique (observable entity)</a></li><li><a href=\"Observation-TransurethralEnucleationIntraductalCarcinoma.html\">Observation Non-infiltrating intraductal carcinoma (morphologic abnormality)</a></li><li><a href=\"Observation-TransurethralEnucleationInvasiveCribriformCarcinoma.html\">Observation Cribriform carcinoma</a></li><li><a href=\"Observation-TransurethralEnucleationProstaticTissueInvolved.html\">Observation Tissue cores.positive.carcinoma in Tissue core</a></li><li><a href=\"Observation-TransurethralEnucleationExtraprostaticExtension.html\">Observation Periprostatic fat invasion [Identifier] in Specimen by CAP cancer protocols</a></li><li><a href=\"Observation-TransurethralEnucleationSeminalVesicleInvasion.html\">Observation Seminal vesicle invasion [Identifier] in Specimen by CAP cancer protocols</a></li><li><a href=\"Observation-TransurethralEnucleationLymphovascularInvasion.html\">Observation Venous + Lymphatic small vessel invasion in Specimen by CAP cancer protocols</a></li><li><a href=\"Observation-TransurethralEnucleationPerineuralInfiltration.html\">Observation Perineural invasion [Presence] in Cancer specimen</a></li></ul><p><b>derivedFrom</b>: <a href=\"QuestionnaireResponse-QuestionnaireResponseTransurethralEnucleation.html\">Response to Questionnaire 'https://art-decor.org/fhir/Questionnaire/2.16.840.1.113883.3.1937.777.18.27.22--20251014150033' about '-&gt;Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)'</a></p></div>"
      },
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        "reference" : "ServiceRequest/TransurethralEnucleationReportRequest"
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      "status" : "final",
      "category" : [{
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
          "code" : "laboratory"
        }]
      }],
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "22637-3"
        }]
      },
      "subject" : {
        "reference" : "Patient/Patient3"
      },
      "effectiveDateTime" : "2024-05-12",
      "performer" : [{
        "reference" : "Practitioner/PathologistPractitioner"
      }],
      "hasMember" : [{
        "reference" : "Observation/TransurethralEnucleationHistologicalTypeICDO3"
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      {
        "reference" : "Observation/TransurethralEnucleationMorphologyFreeText"
      },
      {
        "reference" : "Observation/TransurethralEnucleationPrimaryGleasonPattern"
      },
      {
        "reference" : "Observation/TransurethralEnucleationSecondaryGleasonPattern"
      },
      {
        "reference" : "Observation/TransurethralEnucleationGleasonScoreTotal"
      },
      {
        "reference" : "Observation/TransurethralEnucleationPercentageGleason45"
      },
      {
        "reference" : "Observation/TransurethralEnucleationGradingGroupISUP"
      },
      {
        "reference" : "Observation/TransurethralEnucleationIntraductalCarcinoma"
      },
      {
        "reference" : "Observation/TransurethralEnucleationInvasiveCribriformCarcinoma"
      },
      {
        "reference" : "Observation/TransurethralEnucleationProstaticTissueInvolved"
      },
      {
        "reference" : "Observation/TransurethralEnucleationExtraprostaticExtension"
      },
      {
        "reference" : "Observation/TransurethralEnucleationSeminalVesicleInvasion"
      },
      {
        "reference" : "Observation/TransurethralEnucleationLymphovascularInvasion"
      },
      {
        "reference" : "Observation/TransurethralEnucleationPerineuralInfiltration"
      }],
      "derivedFrom" : [{
        "reference" : "QuestionnaireResponse/QuestionnaireResponseTransurethralEnucleation"
      }]
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/Observation/TransurethralEnucleationMacroscopicGrouper",
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      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_TransurethralEnucleationMacroscopicGrouper\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation TransurethralEnucleationMacroscopicGrouper</b></p><a name=\"TransurethralEnucleationMacroscopicGrouper\"> </a><a name=\"hcTransurethralEnucleationMacroscopicGrouper\"> </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-macroscopic-grouper\">MII PR Patho Macroscopic Grouper</a> version: 2026.0.0</p></div><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 22634-0}\">Pathology report gross observation Narrative</span></p><p><b>subject</b>: <a href=\"Patient-Patient3.html\">Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</a></p><p><b>effective</b>: 2024-04-11 14:00:00+0100</p><p><b>performer</b>: <a href=\"Practitioner-PathologistPractitioner.html\">Practitioner Maria Schneider </a></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 41216001}\">Prostate</span></p><p><b>hasMember</b>: </p><ul><li><a href=\"Observation-TransurethralEnucleationMacroscopicWeight.html\">Observation Specimen weight (observable entity)</a></li><li><a href=\"Observation-TransurethralEnucleationMacroscopicLength.html\">Observation Dimension [Length] of Specimen</a></li><li><a href=\"Observation-TransurethralEnucleationMacroscopicWidth.html\">Observation Dimension [Length] of Specimen</a></li><li><a href=\"Observation-TransurethralEnucleationMacroscopicDepth.html\">Observation Dimension [Length] of Specimen</a></li><li><a href=\"Observation-TransurethralEnucleationMacroscopicSeminalVesicles.html\">Observation Tumor finding</a></li><li><a href=\"Observation-TransurethralEnucleationMacroscopicLymphNodeDissection.html\">Observation Tumor finding</a></li></ul><p><b>derivedFrom</b>: <a href=\"QuestionnaireResponse-QuestionnaireResponseTransurethralEnucleation.html\">Response to Questionnaire 'https://art-decor.org/fhir/Questionnaire/2.16.840.1.113883.3.1937.777.18.27.22--20251014150033' about '-&gt;Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)'</a></p></div>"
      },
      "status" : "final",
      "category" : [{
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
          "code" : "laboratory"
        }]
      }],
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "22634-0"
        }]
      },
      "subject" : {
        "reference" : "Patient/Patient3"
      },
      "effectiveDateTime" : "2024-04-11T14:00:00+01:00",
      "performer" : [{
        "reference" : "Practitioner/PathologistPractitioner"
      }],
      "bodySite" : {
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "41216001",
          "display" : "Prostate"
        }]
      },
      "hasMember" : [{
        "reference" : "Observation/TransurethralEnucleationMacroscopicWeight"
      },
      {
        "reference" : "Observation/TransurethralEnucleationMacroscopicLength"
      },
      {
        "reference" : "Observation/TransurethralEnucleationMacroscopicWidth"
      },
      {
        "reference" : "Observation/TransurethralEnucleationMacroscopicDepth"
      },
      {
        "reference" : "Observation/TransurethralEnucleationMacroscopicSeminalVesicles"
      },
      {
        "reference" : "Observation/TransurethralEnucleationMacroscopicLymphNodeDissection"
      }],
      "derivedFrom" : [{
        "reference" : "QuestionnaireResponse/QuestionnaireResponseTransurethralEnucleation"
      }]
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/Encounter/TransurethralEnucleationEncounter",
    "resource" : {
      "resourceType" : "Encounter",
      "id" : "TransurethralEnucleationEncounter",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_TransurethralEnucleationEncounter\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter TransurethralEnucleationEncounter</b></p><a name=\"TransurethralEnucleationEncounter\"> </a><a name=\"hcTransurethralEnucleationEncounter\"> </a><p><b>identifier</b>: <code>http://example.hospital.de/encounters</code>/E_24_004</p><p><b>status</b>: Finished</p><p><b>class</b>: [not stated]: IMP (IMP)</p><p><b>subject</b>: <a href=\"Patient-Patient3.html\">Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</a></p></div>"
      },
      "identifier" : [{
        "system" : "http://example.hospital.de/encounters",
        "value" : "E_24_004"
      }],
      "status" : "finished",
      "class" : {
        "code" : "IMP"
      },
      "subject" : {
        "reference" : "Patient/Patient3"
      }
    }
  },
  {
    "fullUrl" : "http://prostatecancerspec.org/ServiceRequest/TransurethralEnucleationReportRequest",
    "resource" : {
      "resourceType" : "ServiceRequest",
      "id" : "TransurethralEnucleationReportRequest",
      "meta" : {
        "profile" : ["https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-service-request|2026.0.0"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ServiceRequest_TransurethralEnucleationReportRequest\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest TransurethralEnucleationReportRequest</b></p><a name=\"TransurethralEnucleationReportRequest\"> </a><a name=\"hcTransurethralEnucleationReportRequest\"> </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-service-request\">MII PR Patho Service Request</a> version: 2026.0.0</p></div><p><b>identifier</b>: Placer Identifier/PATH-RPT-2024-004</p><p><b>status</b>: Completed</p><p><b>intent</b>: Order</p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 726007}\">Pathology consultation, comprehensive, records and specimen with report (procedure)</span></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 90470006}\">Prostatectomy (procedure)</span></p><p><b>subject</b>: <a href=\"Patient-Patient3.html\">Klaus Becker  Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)</a></p><p><b>encounter</b>: <a href=\"Encounter-TransurethralEnucleationEncounter.html\">Encounter: identifier = http://example.hospital.de/encounters#E_24_004; status = finished; class = IMP (IMP)</a></p><p><b>requester</b>: <a href=\"Practitioner-UrologistPractitioner.html\">Practitioner Andreas Weber </a></p><p><b>performer</b>: <a href=\"Practitioner-PathologistPractitioner.html\">Practitioner Maria Schneider </a></p><p><b>reasonCode</b>: <span title=\"Codes:{http://snomed.info/sct 266569009}\">Benign prostatic hyperplasia</span></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Observation-TransurethralEnucleationPSAPre.html\">Observation Prostate specific Ag [Mass/volume] in Serum or Plasma</a></li><li><a href=\"Procedure-TransurethralEnucleationProcedure.html\">Procedure Enukleation der Prostata</a></li><li><a href=\"Condition-TransurethralEnucleationDiagnosisBPH.html\">Condition Prostatahyperplasie ohne Beschwerden beim Wasserlassen</a></li></ul><p><b>specimen</b>: <a href=\"Specimen-TransurethralEnucleationSpecimenPart.html\">Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_24_004; status = available; type = Tissue specimen</a></p></div>"
      },
      "identifier" : [{
        "type" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "PLAC",
            "display" : "Placer Identifier"
          }]
        },
        "system" : "http://example.hospital.de/serviceRequest",
        "value" : "PATH-RPT-2024-004"
      }],
      "status" : "completed",
      "intent" : "order",
      "category" : [{
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "726007",
          "display" : "Pathology consultation, comprehensive, records and specimen with report (procedure)"
        }]
      }],
      "code" : {
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "90470006",
          "display" : "Prostatectomy (procedure)"
        }]
      },
      "subject" : {
        "reference" : "Patient/Patient3"
      },
      "encounter" : {
        "reference" : "Encounter/TransurethralEnucleationEncounter"
      },
      "requester" : {
        "reference" : "Practitioner/UrologistPractitioner"
      },
      "performer" : [{
        "reference" : "Practitioner/PathologistPractitioner"
      }],
      "reasonCode" : [{
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "266569009",
          "display" : "Benign prostatic hyperplasia"
        }]
      }],
      "supportingInfo" : [{
        "reference" : "Observation/TransurethralEnucleationPSAPre"
      },
      {
        "reference" : "Procedure/TransurethralEnucleationProcedure"
      },
      {
        "reference" : "Condition/TransurethralEnucleationDiagnosisBPH"
      }],
      "specimen" : [{
        "reference" : "Specimen/TransurethralEnucleationSpecimenPart"
      }]
    }
  }]
}