Lithuanian Breast Diagnostics Implementation Guide
0.0.1 - ci-build Lithuania flag

Lithuanian Breast Diagnostics Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-breast/ and changes regularly. See the Directory of published versions

Questionnaire: Questionnaire: Pathological Histological Examination ESPBI Form (LT Breast)

Official URL: https://hl7.lt/fhir/breast/Questionnaire/questionnaire-pathology-lt-breast Version: 0.0.1
Computable Name: PathologyQuestionnaireLtBreast

Language: en

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. PathologyQuestionnaireLtBreast Questionnaire https://hl7.lt/fhir/breast/Questionnaire/questionnaire-pathology-lt-breast#0.0.1
... grp-referral Referral to perform pathology test 0..1 display Value Set:
... grp-patient Patient information 0..1 group Value Set:
.... patient-personal-code Personal code 0..1 string Value Set:
.... patient-name Name 0..1 string Value Set:
.... patient-surname Surname 0..1 string Value Set:
.... patient-birth-date Date of birth 0..1 date Value Set:
.... patient-age Age 0..1 integer Value Set:
.... patient-gender Gender 0..1 coding Value Set:
Options: 2 options
... grp-specimen-dates Specimen dates 0..1 group Value Set:
.... specimen-collection-date Date of material collection 0..1 dateTime Value Set:
.... specimen-shipment-date Shipment / formation date 0..1 dateTime Value Set:
.... diagnosis-icd10-code Clinical diagnosis ICD-10-AM code 0..1 string Value Set:
.... diagnosis-name Clinical diagnosis name 0..1 text Value Set:
... grp-material Material fixation 0..1 group Value Set:
.... fixation-type Material fixation type 0..1 coding Value Set:
Options: 2 options
... grp-previous-procedures Previous procedures and key clinical data 0..1 group Value Set:
.... previous-procedures Key clinical data 0..* coding Value Set:
Options: 7 options
.... previous-procedures-other Other information 0..1 text Value Set:
... grp-special-tests Special tests 0..1 group Value Set:
.... special-tests-required Special tests required 0..1 text Value Set:
... grp-radiological-data Radiological examination data 0..1 group Value Set:
.... radiology-performed Radiological examination performed 0..1 coding Value Set:
Options: 2 options
.... radiology-exam-type Examination type 0..* coding Value Set:
Options: 3 options
.... radiology-exam-date Examination date 0..1 date Value Set:
.... birads-right BI-RADS right breast 0..1 coding Value Set:
Options: 6 options
.... birads-left BI-RADS left breast 0..1 coding Value Set:
Options: 6 options
... grp-operation Operation details 0..1 group Value Set:
.... operation-nature Nature of operation 0..1 coding Value Set:
Options: 3 options
.... operation-other-details Other operation details 0..1 text Value Set:
... grp-histological-sample Description of histological sample / object 0..1 group Value Set:
.... sample-container-info Container information 0..1 text Value Set:
.... sample-biopsy-location Biopsy location 0..1 text Value Set:
... grp-macroscopic Description of macroscopic examination 0..1 group Value Set:
.... macro-biopsy-size Biopsy size (mm) 0..1 quantity Value Set:
.... macro-fragment-details Fragment details 0..1 text Value Set:
.... macro-notes Notes 0..1 text Value Set:
... grp-microscopic Description of microscopic examination 0..1 group Value Set:
.... microscopic-description Microscopic examination description 0..1 text Value Set:
... grp-ihc Immunohistochemistry (IHC) 0..1 group Value Set:
.... ihc-er-status Estrogen receptors ER 0..1 coding Value Set:
Options: 4 options
.... ihc-er-percent ER expression in nuclei (%) 0..1 quantity Value Set:
.... ihc-pr-status Progesterone receptors PR 0..1 coding Value Set:
Options: 4 options
.... ihc-pr-percent PR expression in nuclei (%) 0..1 quantity Value Set:
.... ihc-her2-status HER2 status 0..1 coding Value Set:
Options: 4 options
.... ihc-her2-evaluation HER2 evaluation 0..1 coding Value Set:
Options: 4 options
.... ihc-ki67 Ki67 proliferation index (%) 0..1 quantity Value Set:
... grp-molecular Molecular studies 0..1 group Value Set:
.... fish-result FISH result 0..1 coding Value Set:
Options: 7 options
.... fish-her2-average HER2 average 0..1 decimal Value Set:
.... fish-cep17-average Average CEP17 0..1 decimal Value Set:
.... fish-her2-cep17-ratio HER2/CEP17 ratio 0..1 decimal Value Set:
.... cish-sish-result CISH/SISH result 0..1 coding Value Set:
Options: 3 options
... grp-conclusion Conclusion 0..1 group Value Set:
.... conclusion-who-diagnosis WHO Classification diagnosis 0..1 text Value Set:
.... conclusion-tumour-grade Tumour grade 0..1 coding Value Set:
Options: 4 options
.... conclusion-tumour-size Tumour size (mm) 0..1 quantity Value Set:
.... conclusion-lvi Lymphovascular invasion 0..1 coding Value Set:
Options: 6 options

doco Documentation for this format

Options Sets

Answer options for patient-gender

  • http://hl7.org/fhir/administrative-gender#male ("Male")
  • http://hl7.org/fhir/administrative-gender#female ("Female")

Answer options for fixation-type

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fixation-formalin ("Fixed (10% formalin buffered solution)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fixation-unfixed ("Unfixed")

Answer options for previous-procedures

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-none ("No important information")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-biopsy ("Biopsy")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-excision ("Excision")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-other-operation ("Other operation")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-chemotherapy ("Chemotherapy")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-radiation ("Radiation (breast)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#proc-immunotherapy ("Immunotherapy")

Answer options for radiology-performed

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#yes ("Yes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#no ("No")

Answer options for radiology-exam-type

  • http://snomed.info/sct#71651007 ("Mammography")
  • http://snomed.info/sct#439324009 ("Digital breast tomosynthesis")
  • http://snomed.info/sct#16310003 ("Ultrasonography")

Answer options for birads-right

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-0 ("BI-RADS 0 – Incomplete examination")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-1 ("BI-RADS 1 – No changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-2 ("BI-RADS 2 – Benign changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-3 ("BI-RADS 3 – Possibly benign changes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-4 ("BI-RADS 4 – Suspicious malignant finding")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-5 ("BI-RADS 5 – Highly probable malignant finding")

Answer options for birads-left

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-0 ("BI-RADS 0 – Incomplete examination")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-1 ("BI-RADS 1 – No changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-2 ("BI-RADS 2 – Benign changes found")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-3 ("BI-RADS 3 – Possibly benign changes")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-4 ("BI-RADS 4 – Suspicious malignant finding")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#birads-5 ("BI-RADS 5 – Highly probable malignant finding")

Answer options for operation-nature

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#op-thick-needle-biopsy ("Thick needle biopsy")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#op-excision ("Excision")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#op-other ("Other (free text)")

Answer options for ihc-er-status

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-negative ("Negative")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-weak ("Weak (+)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-moderate ("Moderate (++)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-strong ("Strong (+++)")

Answer options for ihc-pr-status

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-negative ("Negative")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-weak ("Weak (+)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-moderate ("Moderate (++)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#ihc-strong ("Strong (+++)")

Answer options for ihc-her2-status

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-negative ("HER2: expression absent (0)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-low ("HER2: low immunohistochemical expression (1+)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-borderline ("HER2: expression borderline (2+)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-positive ("HER2: expression positive (3+)")

Answer options for ihc-her2-evaluation

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-eval-0 ("HER2 evaluation: 0+")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-eval-1 ("HER2 evaluation: 1+")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-eval-2 ("HER2 evaluation: 2+")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#her2-eval-3 ("HER2 evaluation: 3+")

Answer options for fish-result

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-amplified ("FISH: HER2 amplified")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-amplified-clusters ("FISH: amplified (clusters)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-co-amplified ("FISH: co-amplified (HER2>=6, HER2/CEP17<2)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-borderline ("FISH: borderline (4<=HER2<6, HER2/CEP17<2)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-monosomic ("FISH: monosomic (HER2<4, HER2/CEP17>=2)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-negative ("FISH: negative (HER2<4, HER2/CEP17<2)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#fish-not-evaluated ("FISH: not to be evaluated")

Answer options for cish-sish-result

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#cish-amplified ("CISH/SISH: HER2 amplified")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#cish-not-amplified ("CISH/SISH: HER2 not amplified")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#cish-not-evaluated ("CISH/SISH: not to be evaluated")

Answer options for conclusion-tumour-grade

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#grade-g1 ("G1 (well-differentiated)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#grade-g2 ("G2 (moderately differentiated)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#grade-g3 ("G3 (poorly differentiated)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#grade-gx ("Gx (degree of differentiation undetermined)")

Answer options for conclusion-lvi

  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-0 ("pLVI-0: not detected")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-1 ("pLVI-1: spreading, otherwise unclassified")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-2 ("pLVI-2: only in lymphatic vessels and small blood vessels")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-3 ("pLVI-3: only in veins (large, thick-walled blood vessels)")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-4 ("pLVI-4: present in both lymphatic vessels and veins")
  • https://tx.hl7.lt/fhir/CodeSystem/breast-questionnaire-options#lvi-9 ("pLVI-9: undetectable/unknown")

Language: en

Referral to perform pathology test

  • linkId: grp-referral
  • Answers:

Patient information

  • linkId: grp-patient
  • Answers:

Personal code

  • linkId: patient-personal-code
  • Answers:

Name

  • linkId: patient-name
  • Answers:

Surname

  • linkId: patient-surname
  • Answers:

Date of birth

  • linkId: patient-birth-date
  • Answers:

Age

  • linkId: patient-age
  • Answers:

Gender

Specimen dates

  • linkId: grp-specimen-dates
  • Answers:

Date of material collection

  • linkId: specimen-collection-date
  • Answers:

Shipment / formation date

  • linkId: specimen-shipment-date
  • Answers:

Clinical diagnosis

  • linkId: grp-clinical-diagnosis
  • Answers:

Clinical diagnosis ICD-10-AM code

  • linkId: diagnosis-icd10-code
  • Answers:

Clinical diagnosis name

  • linkId: diagnosis-name
  • Answers:

Material fixation

  • linkId: grp-material
  • Answers:

Material fixation type

Previous procedures and key clinical data

  • linkId: grp-previous-procedures
  • Answers:

Key clinical data

Other information

  • linkId: previous-procedures-other
  • Answers:

Special tests

  • linkId: grp-special-tests
  • Answers:

Special tests required

  • linkId: special-tests-required
  • Answers:

Radiological examination data

  • linkId: grp-radiological-data
  • Answers:

Radiological examination performed

Examination type

Examination date

  • linkId: radiology-exam-date
  • Answers:

BI-RADS right breast

BI-RADS left breast

Operation details

  • linkId: grp-operation
  • Answers:

Nature of operation

Other operation details

  • linkId: operation-other-details
  • Answers:

Description of histological sample / object

  • linkId: grp-histological-sample
  • Answers:

Container information

  • linkId: sample-container-info
  • Answers:

Biopsy location

  • linkId: sample-biopsy-location
  • Answers:

Description of macroscopic examination

  • linkId: grp-macroscopic
  • Answers:

Biopsy size (mm)

  • linkId: macro-biopsy-size
  • Answers:

Fragment details

  • linkId: macro-fragment-details
  • Answers:

Notes

  • linkId: macro-notes
  • Answers:

Description of microscopic examination

  • linkId: grp-microscopic
  • Answers:

Microscopic examination description

  • linkId: microscopic-description
  • Answers:

Immunohistochemistry (IHC)

  • linkId: grp-ihc
  • Answers:

Estrogen receptors ER

ER expression in nuclei (%)

  • linkId: ihc-er-percent
  • Answers:

Progesterone receptors PR

PR expression in nuclei (%)

  • linkId: ihc-pr-percent
  • Answers:

HER2 status

HER2 evaluation

Ki67 proliferation index (%)

  • linkId: ihc-ki67
  • Answers:

Molecular studies

  • linkId: grp-molecular
  • Answers:

FISH result

HER2 average

  • linkId: fish-her2-average
  • Answers:

Average CEP17

  • linkId: fish-cep17-average
  • Answers:

HER2/CEP17 ratio

  • linkId: fish-her2-cep17-ratio
  • Answers:

CISH/SISH result

Conclusion

  • linkId: grp-conclusion
  • Answers:

WHO Classification diagnosis

  • linkId: conclusion-who-diagnosis
  • Answers:

Tumour grade

Tumour size (mm)

  • linkId: conclusion-tumour-size
  • Answers:

Lymphovascular invasion

Language: en

LinkIDDescription & Constraintsdoco
.. grp-referral Value Set:
.. grp-patient Value Set:
... patient-personal-code Value Set:
... patient-name Value Set:
... patient-surname Value Set:
... patient-birth-date Value Set:
... patient-age Value Set:
... patient-gender Value Set:
Options: 2 options
.. grp-specimen-dates Value Set:
... specimen-collection-date Value Set:
... specimen-shipment-date Value Set:
.. grp-clinical-diagnosis Value Set:
... diagnosis-icd10-code Value Set:
... diagnosis-name Value Set:
.. grp-material Value Set:
... fixation-type Value Set:
Options: 2 options
.. grp-previous-procedures Value Set:
... previous-procedures Value Set:
Options: 7 options
... previous-procedures-other Value Set:
.. grp-special-tests Value Set:
... special-tests-required Value Set:
.. grp-radiological-data Value Set:
... radiology-performed Value Set:
Options: 2 options
... radiology-exam-type Value Set:
Options: 3 options
... radiology-exam-date Value Set:
... birads-right Value Set:
Options: 6 options
... birads-left Value Set:
Options: 6 options
.. grp-operation Value Set:
... operation-nature Value Set:
Options: 3 options
... operation-other-details Value Set:
.. grp-histological-sample Value Set:
... sample-container-info Value Set:
... sample-biopsy-location Value Set:
.. grp-macroscopic Value Set:
... macro-biopsy-size Value Set:
... macro-fragment-details Value Set:
... macro-notes Value Set:
.. grp-microscopic Value Set:
... microscopic-description Value Set:
.. grp-ihc Value Set:
... ihc-er-status Value Set:
Options: 4 options
... ihc-er-percent Value Set:
... ihc-pr-status Value Set:
Options: 4 options
... ihc-pr-percent Value Set:
... ihc-her2-status Value Set:
Options: 4 options
... ihc-her2-evaluation Value Set:
Options: 4 options
... ihc-ki67 Value Set:
.. grp-molecular Value Set:
... fish-result Value Set:
Options: 7 options
... fish-her2-average Value Set:
... fish-cep17-average Value Set:
... fish-her2-cep17-ratio Value Set:
... cish-sish-result Value Set:
Options: 3 options
.. grp-conclusion Value Set:
... conclusion-who-diagnosis Value Set:
... conclusion-tumour-grade Value Set:
Options: 4 options
... conclusion-tumour-size Value Set:
... conclusion-lvi Value Set:
Options: 6 options

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire