Prostate Cancer Specification
0.1.0 - ci-build
Prostate Cancer Specification
0.1.0 - ci-build
Prostate Cancer Specification - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
{
"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",
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"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>"
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"system" : "http://example.hospital.de/pathology-reports",
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"subject" : {
🔗 "reference" : "Patient/Patient3",
"display" : "Klaus Becker, geb. 10.11.1958 (PAT-2024-003)"
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"title" : "Histopathologischer Befundbericht - Prostata Enucleation",
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🔗 "reference" : "Organization/PathologyLabOrganization"
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"section" : [
{
"title" : "Pathologiebefundbericht",
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"code" : "60567-5",
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},
"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>"
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"entry" : [
{
🔗 "reference" : "DiagnosticReport/TransurethralEnucleationReport"
}
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}
},
{
"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>"
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"identifier" : [
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"system" : "http://example.hospital.de/patient-ids",
"value" : "PAT-2024-003"
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"name" : [
{
"family" : "Becker",
"given" : [
"Klaus"
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],
"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",
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🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2026.0.0"
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"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&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>"
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"identifier" : [
{
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"code" : "ACSN",
"display" : "Accession ID"
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"system" : "https://pathologie.example-hospital.de/fhir/fn/befundbericht",
"value" : "E_24_004"
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{
🔗 "reference" : "ServiceRequest/TransurethralEnucleationReportRequest"
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"status" : "final",
"category" : [
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"system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
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"code" : {
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{
"system" : "http://loinc.org",
"code" : "60568-3",
"display" : "Pathology Synoptic report"
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"subject" : {
🔗 "reference" : "Patient/Patient3"
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"effectiveDateTime" : "2024-05-12T17:00:00+01:00",
"issued" : "2024-05-13T08:00:00+01:00",
"performer" : [
{
🔗 "reference" : "Practitioner/PathologistPractitioner"
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"specimen" : [
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenPart"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenBlock01"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide01A"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide01B"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenBlock02"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide02A"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide02B"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenBlock03"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide03A"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide03B"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenBlock04"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide04A"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide04B"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenBlock05"
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🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide05A"
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{
🔗 "reference" : "Specimen/TransurethralEnucleationSpecimenSlide05B"
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"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",
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"meta" : {
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"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&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 '->Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)'</a></p></div>"
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"code" : "laboratory"
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"code" : "22637-3"
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"subject" : {
🔗 "reference" : "Patient/Patient3"
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"effectiveDateTime" : "2024-05-12",
"performer" : [
{
🔗 "reference" : "Practitioner/PathologistPractitioner"
}
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"hasMember" : [
{
🔗 "reference" : "Observation/TransurethralEnucleationHistologicalTypeICDO3"
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{
🔗 "reference" : "Observation/TransurethralEnucleationMorphologyFreeText"
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{
🔗 "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"
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{
🔗 "reference" : "QuestionnaireResponse/QuestionnaireResponseTransurethralEnucleation"
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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&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 '->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&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"
}
]
}
}
]
}