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 - XML Representation

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="RadicalProstatectomyReport"/>
  <meta>
    <profile
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2026.0.0"/>
  </meta>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
      </coding>
    </type>
    <system
            value="https://pathologie.example-hospital.de/fhir/fn/befundbericht"/>
    <value value="E_24_002"/>
  </identifier>
  <basedOn>🔗 
    <reference value="ServiceRequest/RadicalProstatectomyReportRequest"/>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="SP"/>
      <display value="Surgical Pathology"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="60568-3"/>
      <display value="Pathology Synoptic report"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/Patient1"/>
  </subject>
  <effectiveDateTime value="2024-03-20T17:00:00+01:00"/>
  <issued value="2024-03-21T08:00:00+01:00"/>
  <performer>🔗 
    <reference value="Practitioner/PathologistPractitioner"/>
  </performer>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenPart"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenBlock01"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide01A"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide01B"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenBlock02"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide02A"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide02B"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenBlock03"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide03A"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenSlide03B"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenLymphNodeRight"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeRightBlock"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeRightSlide01"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeRightSlide02"/>
  </specimen>
  <specimen>🔗 
    <reference value="Specimen/RadicalProstatectomySpecimenLymphNodeLeft"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeLeftBlock"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeLeftSlide01"/>
  </specimen>
  <specimen>🔗 
    <reference
               value="Specimen/RadicalProstatectomySpecimenLymphNodeLeftSlide02"/>
  </specimen>
  <result>🔗 
    <reference value="Observation/RadicalProstatectomyMacroscopicGrouper"/>
  </result>
  <result>🔗 
    <reference
               value="Observation/RadicalProstatectomyDiagnosticConclusionGrouper"/>
  </result>
  <conclusion
              value="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."/>
</DiagnosticReport>