Kerndatensatz Senologie
0.9.0 - ci-build
Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
{
"resourceType" : "DiagnosticReport",
"id" : "Fall3-Pathologie-Befund",
"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 Fall3-Pathologie-Befund</b></p><a name=\"Fall3-Pathologie-Befund\"> </a><a name=\"hcFall3-Pathologie-Befund\"> </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>Sabine Weber Female, DoB: 1953-07-15 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-003)</td></tr><tr><td>When For</td><td>2025-03-15</td></tr><tr><td>Reported</td><td>2025-03-18 14:00:00+0100</td></tr><tr><td>Performer</td><td> Institut für Pathologie, Charité - Universitätsmedizin Berlin</td></tr><tr><td>Identifier</td><td> Accession ID/PATH-2025-000789</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-Fall3-Patho-Conclusion.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td>Invasives Karzinom NST, G2, pT2, ER+ IRS 10, PR+ IRS 6, HER2- Score 0, Ki-67 12%</td><td>Final</td><td>2025-03-18</td></tr></table><p>Invasives Karzinom NST, G2, ER+ IRS 10, PR+ IRS 6, HER2- Score 0, Ki-67 12%</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-2025-000789"
}
],
"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/Fall3-Patient-Sabine-Weber"
},
"effectiveDateTime" : "2025-03-15",
"issued" : "2025-03-18T14:00:00+01:00",
"performer" : [
{
"display" : "Institut für Pathologie, Charité - Universitätsmedizin Berlin"
}
],
"specimen" : [
{
🔗 "reference" : "Specimen/Fall3-Pathologie-Praeparat-Stanze"
}
],
"result" : [
{
🔗 "reference" : "Observation/Fall3-Patho-Conclusion"
}
],
"conclusion" : "Invasives Karzinom NST, G2, ER+ IRS 10, PR+ IRS 6, HER2- Score 0, Ki-67 12%"
}