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: Fall 12: Pathologie Nachresektion — ADH, kein Upgrade, R0 - JSON Representation

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{
  "resourceType" : "DiagnosticReport",
  "id" : "Fall12-Pathologie-Befund-Nachresektion",
  "meta" : {
    "profile" : [
      🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-pathologie-befund"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport Fall12-Pathologie-Befund-Nachresektion</b></p><a name=\"Fall12-Pathologie-Befund-Nachresektion\"> </a><a name=\"hcFall12-Pathologie-Befund-Nachresektion\"> </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=\"StructureDefinition-senologie-pathologie-befund.html\">BIH Senologie Pathologie Befund</a></p></div><h2><span title=\"Codes:{http://loinc.org 60568-3}\">Pathologischer Befund</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 SP}\">Surgical Pathology</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Renate Vogel  Female, DoB: 1981-03-06 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-012)</td></tr><tr><td>When For</td><td>2025-08-05</td></tr><tr><td>Reported</td><td>2025-08-08 14:00:00+0200</td></tr><tr><td>Performer</td><td> Institut für Pathologie, Universitätsklinikum Bonn</td></tr><tr><td>Identifier</td><td> Accession ID/PATH-2025-001202</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>When For</b></td></tr><tr><td><a href=\"Observation-Fall12-Patho-Conclusion-Nachresektion.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td>ADH bestätigt, R0 reseziert. Kein DCIS, kein invasives Karzinom. Kein Upgrade. Keine weitere Therapie erforderlich.</td><td>Final</td><td>2025-08-08</td></tr></table><p>Exzisionspräparat: Atypische duktale Hyperplasie (ADH), R0 reseziert. Kein DCIS, kein invasives Karzinom. Kein Upgrade.</p></div>"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "ACSN",
            "display" : "Accession ID"
          }
        ]
      },
      "system" : "http://pathologie.charite.de/fhir/sid/report-id",
      "value" : "PATH-2025-001202"
    }
  ],
  "basedOn" : [
    {
      "display" : "Anforderung Histologie durch Senologie"
    }
  ],
  "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"
      }
    ],
    "text" : "Pathologischer Befund"
  },
  "subject" : {
    🔗 "reference" : "Patient/Fall12-Patient-Renate-Vogel"
  },
  "effectiveDateTime" : "2025-08-05",
  "issued" : "2025-08-08T14:00:00+02:00",
  "performer" : [
    {
      "display" : "Institut für Pathologie, Universitätsklinikum Bonn"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/Fall12-Pathologie-Praeparat-Nachresektion"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/Fall12-Patho-Conclusion-Nachresektion"
    }
  ],
  "conclusion" : "Exzisionspräparat: Atypische duktale Hyperplasie (ADH), R0 reseziert. Kein DCIS, kein invasives Karzinom. Kein Upgrade."
}