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Generated Narrative: Composition composition-cervical-screening-episode-example

IM Document DiagnosticReport Reference: Diagnostic Report for 'Diagnostic studies report (record artifact)' for '->Janette Petrauskaite(official) Female, DoB: 1985-01-01 ( http://hospital-lt.lt/patient-id#HOSPLT-10005 (use: usual, ))'

identifier: urn:oid:2.16.840.1.113883.4.330.1/CERVICAL-COMP-2025-0001

status: Final

type: Imaging Report V0.0.1

category: Diagnostic imaging study

date: 2025-03-20

author: PractitionerRole Gynecologist (occupation)

title: Cervical Cancer Screening Episode

event

Details

-Concept
*Ultrasound

event

Details

-Concept
*Screening for malignant neoplasm of cervix (procedure)
 <event> <detail> <concept> <coding> <system value="http://dicom.nema.org/resources/ontology/DCM"/> <code value="US"/> <display value="Ultrasound"/> </coding> </concept> </detail> </event> <event> <detail> <concept> <coding> <system value="http://snomed.info/sct"/> <code value="71341001"/> <display value="Screening for malignant neoplasm of cervix (procedure)"/> </coding> </concept> </detail> </event> <section> <title value="Imaging Study"/> <code> <coding> <system value="http://loinc.org"/> <code value="18726-0"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Not applicable for this cervical screening episode.</p></div> </text> <entry> <display value="No imaging study"/> </entry> </section> <section> <title value="Order"/> <code> <coding> <system value="http://loinc.org"/> <code value="55115-0"/> <display value="Requested imaging studies information Document"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Cervical cancer screening referral.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="Comparison"/> <code> <coding> <system value="http://loinc.org"/> <code value="18834-2"/> <display value="Radiology Comparison study (narrative)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>No prior studies available for comparison.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="Clinical History"/> <code> <coding> <system value="http://loinc.org"/> <code value="11329-0"/> <display value="History general Narrative - Reported"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Regular menstrual cycle, day 14. No hormone therapy. No previous conization.</p></div> </text> <entry> <reference value="Observation/observation-clinical-history-routine-example"/> </entry> </section> <section> <title value="Colposcopy Procedure"/> <code> <coding> <system value="http://loinc.org"/> <code value="55111-9"/> <display value="Current imaging procedure descriptions Document"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Colposcopy performed on 2025-02-10.</p></div> </text> <entry> <reference value="Procedure/procedure-colposcopy-example"/> </entry> </section> <section> <title value="Findings"/> <code> <coding> <system value="http://loinc.org"/> <code value="59776-5"/> <display value="Findings"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>HPV 16 detected. Cytology: LSIL. Colposcopy: adequate, Swede score 3, low risk.</p></div> </text> <entry> <reference value="Observation/observation-hpv-result-example"/> </entry> <entry> <reference value="Observation/observation-cytology-conclusion-example"/> </entry> <entry> <reference value="Observation/observation-colposcopy-finding-example"/> </entry> </section> <section> <title value="Impression"/> <code> <coding> <system value="http://loinc.org"/> <code value="19005-8"/> <display value="Radiology Imaging study [Impression] (narrative)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Low-risk findings. Follow-up in 12 months recommended.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="Recommendations"/> <code> <coding> <system value="http://loinc.org"/> <code value="18783-1"/> <display value="Radiology Study recommendation (narrative)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Repeat HPV and cytology in 12 months.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="Communications"/> <code> <coding> <system value="http://loinc.org"/> <code value="73568-8"/> <display value="Communication of critical results [Description] Document"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>No additional communications.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="HPV Testing"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="35904009"/> <display value="Human papillomavirus deoxyribonucleic acid detection (procedure)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>HPV DNA detected: type 16.</p></div> </text> <entry> <reference value="DiagnosticReport/diagnosticreport-hpv-example"/> </entry> </section> <section> <title value="Cervical Cytology (Pap Test)"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="416107004"/> <display value="Cervical cytology test (procedure)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Cytology conclusion: LSIL.</p></div> </text> <entry> <reference value="DiagnosticReport/diagnosticreport-cytology-example"/> </entry> </section> <section> <title value="Colposcopy Examination"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="392003006"/> <display value="Colposcopy (procedure)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Colposcopy: adequate, Swede score 3, low risk.</p></div> </text> <entry> <reference value="DiagnosticReport/diagnosticreport-colposcopy-example"/> </entry> </section> <section> <title value="Lifestyle Factors"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="443781008"/> <display value="Assessment of lifestyle (procedure)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>See <a href="https://build.fhir.org/ig/HL7LT/ig-lt-lifestyle/Observation-observation-tobacco-use-example.html">Tobacco Use</a> and <a href="https://build.fhir.org/ig/HL7LT/ig-lt-lifestyle/Observation-observation-physical-activity-example.html">Physical Activity</a> examples from the Lifestyle IG.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> <section> <title value="Vital Signs"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="118227000"/> <display value="Vital signs finding (finding)"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>See <a href="https://build.fhir.org/ig/HL7LT/ig-lt-vitalsigns/Observation-observation-bmi-example.html">BMI</a> example from the VitalSigns IG.</p></div> </text> <emptyReason> <coding> <system value="http://terminology.hl7.org/CodeSystem/list-empty-reason"/> <code value="unavailable"/> <display value="Unavailable"/> </coding> </emptyReason> </section> </Composition>