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" : "Fall4-Bildgebung-Mammographie",
"meta" : {
"profile" : [
🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-bildgebung-befund"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport Fall4-Bildgebung-Mammographie</b></p><a name=\"Fall4-Bildgebung-Mammographie\"> </a><a name=\"hcFall4-Bildgebung-Mammographie\"> </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-bildgebung-befund.html\">BIH Senologie Bildgebung Befund</a></p></div><h2><span title=\"Codes:{http://loinc.org 24606-6}\">Mammographie bilateral</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 RAD}\">Radiology</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Julia Fischer Female, DoB: 1987-11-22 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-004)</td></tr><tr><td>When For</td><td>2025-02-18</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>Note</b></td></tr><tr><td><a href=\"Observation-Fall4-BiRADS-Links.html\"><span title=\"Codes:{http://loinc.org 72018-2}\">Breast Imaging-Reporting and Data System (BI-RADS) assessment category</span></a> (<span title=\"Codes:{http://snomed.info/sct 80248007}\">Left breast structure</span>)</td><td><span title=\"Codes:{http://snomed.info/sct 397145000}\">BI-RADS 5 — hochverdächtig auf Malignität</span></td><td>Final</td><td><blockquote><div><p>Herdbefund links, 32 mm, irregulär, suspekte axilläre LK links</p>\n</div></blockquote></td></tr></table><p>BI-RADS 5 links, 32 mm Herdbefund, irregulär. BI-RADS 1 rechts.</p></div>"
},
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
"code" : "RAD",
"display" : "Radiology"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "24606-6",
"display" : "MG Breast Screening"
}
],
"text" : "Mammographie bilateral"
},
"subject" : {
🔗 "reference" : "Patient/Fall4-Patient-Julia-Fischer"
},
"effectiveDateTime" : "2025-02-18",
"result" : [
{
🔗 "reference" : "Observation/Fall4-BiRADS-Links"
}
],
"conclusion" : "BI-RADS 5 links, 32 mm Herdbefund, irregulär. BI-RADS 1 rechts."
}