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

: Fall 9: Pathologie — Invasives lobuläres Karzinom, G2, HR+/HER2- - JSON Representation

Raw json | Download

{
  "resourceType" : "DiagnosticReport",
  "id" : "Fall9-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 Fall9-Pathologie-Befund</b></p><a name=\"Fall9-Pathologie-Befund\"> </a><a name=\"hcFall9-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>Andrea Wolf  Female, DoB: 1974-05-29 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-009)</td></tr><tr><td>When For</td><td>2025-04-08</td></tr><tr><td>Reported</td><td>2025-04-11 10:00:00+0200</td></tr><tr><td>Performer</td><td> Institut für Pathologie, Universitätsklinikum Stuttgart</td></tr><tr><td>Identifier</td><td> Accession ID/PATH-2025-000901</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-Fall9-Patho-Conclusion.html\"><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span></a></td><td>Invasives lobuläres Karzinom, G2, pT2, ER+ IRS 12, PR+ IRS 10, HER2- Score 0, Ki-67 20%, E-Cadherin negativ</td><td>Final</td><td>2025-04-11</td></tr></table><p>Invasives lobuläres Karzinom, G2, ER+ IRS 12, PR+ IRS 10, HER2- Score 0, Ki-67 20%</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-2025-000901"
    }
  ],
  "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/Fall9-Patient-Andrea-Wolf"
  },
  "effectiveDateTime" : "2025-04-08",
  "issued" : "2025-04-11T10:00:00+02:00",
  "performer" : [
    {
      "display" : "Institut für Pathologie, Universitätsklinikum Stuttgart"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/Fall9-Pathologie-Praeparat"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/Fall9-Patho-Conclusion"
    }
  ],
  "conclusion" : "Invasives lobuläres Karzinom, G2, ER+ IRS 12, PR+ IRS 10, HER2- Score 0, Ki-67 20%"
}