minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0-ballot - STU4 Ballot United States of America flag

minimal Common Oncology Data Elements (mCODE) Implementation Guide, published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-mCODE-ig/ and changes regularly. See the Directory of published versions

: us-core-diagnosticreport-lab-jenny-m - JSON Representation

Raw json | Download

{
  "resourceType" : "DiagnosticReport",
  "id" : "us-core-diagnosticreport-lab-jenny-m",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport us-core-diagnosticreport-lab-jenny-m</b></p><a name=\"us-core-diagnosticreport-lab-jenny-m\"> </a><a name=\"hcus-core-diagnosticreport-lab-jenny-m\"> </a><a name=\"us-core-diagnosticreport-lab-jenny-m-en-US\"> </a><h2><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 LAB}\">Laboratory</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Jenny M  Female, DoB: 1965-01-01 ( Medical Record Number: MRN1234\u00a0(use:\u00a0usual,\u00a0))</td></tr><tr><td>When For</td><td>2018-04-01 00:00:00+0000</td></tr><tr><td>Reported</td><td>2018-04-05 00:00:00+0000</td></tr><tr><td>Performer</td><td> <a href=\"Practitioner-us-core-practitioner-owen-oncologist.html\">Practitioner Owen Oncologist </a></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-us-core-observation-lab-tumor-invasion-jenny-m.html\"><span title=\"Codes:{http://snomed.info/sct 370052007}\">Status of invasion by tumor</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 260385009}\">Negative (qualifier value)</span></td><td>Final</td><td/></tr><tr><td><a href=\"Observation-us-core-observation-lab-tumor-margins-jenny-m.html\"><span title=\"Codes:{http://loinc.org 44669-0}\">Margin involvement in Breast tumor</span></a></td><td><span title=\"Codes:{http://loinc.org LA27151-2}\">Uninvolved by invasive carcinoma</span></td><td>Final</td><td/></tr><tr><td><a href=\"Observation-us-core-observation-lab-sentinel-nodes-jenny-m.html\"><span title=\"Codes:{http://loinc.org 92832-5}\">Sentinel lymph nodes with metastasis [#] in Cancer specimen</span></a></td><td/><td>Final</td><td/></tr><tr><td><a href=\"Observation-tumor-size-jenny-m.html\"><span title=\"Codes:{http://loinc.org 21889-1}\">Size Tumor</span></a></td><td/><td>Final</td><td/></tr><tr><td><a href=\"Observation-us-core-observation-lab-tumor-dcis-jenny-m.html\"><span title=\"Codes:{http://loinc.org 85336-6}\">DCIS intraductal extension in Breast cancer specimen Qualitative by Light microscopy</span></a></td><td><span title=\"Codes:{http://loinc.org LA27261-9}\">DCIS present with extensive intraductal component (EIC)</span></td><td>Final</td><td/></tr><tr><td><a href=\"Observation-tumor-marker-test-her2-jenny-m.html\"><span title=\"Codes:{http://loinc.org 48676-1}\">HER2 [Interpretation] in Tissue</span></a></td><td><span title=\"Codes:{http://loinc.org LA6577-6}\">Negative</span></td><td>Final</td><td>2018-03-10</td></tr><tr><td><a href=\"Observation-tumor-marker-test-er-jenny-m.html\"><span title=\"Codes:{http://loinc.org 85337-4}\">Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain</span></a></td><td><span title=\"Codes:{http://loinc.org LA6576-8}\">Positive</span></td><td>Final</td><td>2018-03-10</td></tr><tr><td><a href=\"Observation-tumor-marker-test-pr-jenny-m.html\"><span title=\"Codes:{http://loinc.org 85339-0}\">Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain</span></a></td><td><span title=\"Codes:{http://loinc.org LA6577-6}\">Negative</span></td><td>Final</td><td>2018-03-10</td></tr><tr><td><a href=\"Observation-us-core-observation-lab-tumor-grade-jenny-m.html\"><span title=\"Codes:{http://loinc.org 44648-4}\">Histologic grade [Score] in Breast cancer specimen by Nottingham</span></a></td><td><span title=\"Codes:{http://loinc.org LA27824-4}\">Nottingham grade 2</span></td><td>Final</td><td/></tr></table></div>"
  },
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "LAB"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "22637-3",
        "display" : "Pathology report final diagnosis Narrative"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/cancer-patient-jenny-m"
  },
  "effectiveDateTime" : "2018-04-01T00:00:00Z",
  "issued" : "2018-04-05T00:00:00Z",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/us-core-practitioner-owen-oncologist"
    }
  ],
  "resultsInterpreter" : [
    {
      🔗 "reference" : "Practitioner/us-core-practitioner-peter-pathologist"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/tumor-specimen-left-breast-jenny-m"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/us-core-observation-lab-tumor-invasion-jenny-m"
    },
    {
      🔗 "reference" : "Observation/us-core-observation-lab-tumor-margins-jenny-m"
    },
    {
      🔗 "reference" : "Observation/us-core-observation-lab-sentinel-nodes-jenny-m"
    },
    {
      🔗 "reference" : "Observation/tumor-size-jenny-m"
    },
    {
      🔗 "reference" : "Observation/us-core-observation-lab-tumor-dcis-jenny-m"
    },
    {
      🔗 "reference" : "Observation/tumor-marker-test-her2-jenny-m"
    },
    {
      🔗 "reference" : "Observation/tumor-marker-test-er-jenny-m"
    },
    {
      🔗 "reference" : "Observation/tumor-marker-test-pr-jenny-m"
    },
    {
      🔗 "reference" : "Observation/us-core-observation-lab-tumor-grade-jenny-m"
    }
  ]
}