Prostate 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 Prostatektomie - JSON Representation

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{
  "resourceType" : "DiagnosticReport",
  "id" : "RadicalProstatectomyReport",
  "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 RadicalProstatectomyReport</b></p><a name=\"RadicalProstatectomyReport\"> </a><a name=\"hcRadicalProstatectomyReport\"> </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>Hans Mueller  Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)</td></tr><tr><td>Relevant Time</td><td>2024-03-20 17:00:00+0100</td></tr><tr><td>Reported</td><td>2024-03-21 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_002</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-RadicalProstatectomyMacroscopicGrouper.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>Makroskopische Messungen des Prostatektomiepräparats</td><td>Final</td><td>2024-03-16 14:00:00+0100</td></tr><tr><td><a href=\"Observation-RadicalProstatectomyDiagnosticConclusionGrouper.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td/><td>Final</td><td>2024-03-20</td></tr></table><p>Adenokarzinom der Prostata, Gleason Score 3+4=7, pT2 pN0 (0/12) R0. Maximaler Tumordurchmesser 18 mm (ca. 25% der Prostata). Keine extrakapsuläre Extension, keine Samenblaseninvasion, alle Resektionsränder tumorfrei.</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_002"
    }
  ],
  "basedOn" : [
    {
      🔗 "reference" : "ServiceRequest/RadicalProstatectomyReportRequest"
    }
  ],
  "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/Patient1"
  },
  "effectiveDateTime" : "2024-03-20T17:00:00+01:00",
  "issued" : "2024-03-21T08:00:00+01:00",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/PathologistPractitioner"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenPart"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenBlock01"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide01A"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide01B"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenBlock02"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide02A"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide02B"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenBlock03"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide03A"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenSlide03B"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeRight"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeRightBlock"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeRightSlide01"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeRightSlide02"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeLeft"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeLeftBlock"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeLeftSlide01"
    },
    {
      🔗 "reference" : "Specimen/RadicalProstatectomySpecimenLymphNodeLeftSlide02"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/RadicalProstatectomyMacroscopicGrouper"
    },
    {
      🔗 "reference" : "Observation/RadicalProstatectomyDiagnosticConclusionGrouper"
    }
  ],
  "conclusion" : "Adenokarzinom der Prostata, Gleason Score 3+4=7, pT2 pN0 (0/12) R0. Maximaler Tumordurchmesser 18 mm (ca. 25% der Prostata). Keine extrakapsuläre Extension, keine Samenblaseninvasion, alle Resektionsränder tumorfrei."
}