Lithuanian Cervical Cancer Implementation Guide
0.0.1 - ci-build Lithuania flag

Lithuanian Cervical Cancer 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-cervical/ and changes regularly. See the Directory of published versions

Questionnaire: Cervical Histopathological Examination – ESPBI Form

Official URL: https://hl7.lt/fhir/cervical/Questionnaire/questionnaire-cervical-histology-espbi Version: 0.0.1
Computable Name: CervicalHistologyEspbiQuestionnaire

Structured questionnaire capturing cervical histopathological examination data for the Lithuanian ESPBI system, aligned with ADP Table 7.2.

Language: en

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. CervicalHistologyEspbiQuestionnaire Structured questionnaire capturing cervical histopathological examination data for the Lithuanian ESPBI system, aligned with ADP Table 7.2. Questionnaire https://hl7.lt/fhir/cervical/Questionnaire/questionnaire-cervical-histology-espbi#0.0.1
... referral Referral to perform pathology test 0..1 group Value Set:
.... referral.personalCode Personal code 1..1 string Value Set:
.... referral.name Name 1..1 string Value Set:
.... referral.surname Surname 1..1 string Value Set:
.... referral.dateOfBirth Date of birth 0..1 date Value Set:
.... referral.clinicalDiagnosis Clinical diagnosis (ICD-10 code with name) 0..1 string Value Set:
... previousProcedures Previous procedures history 0..1 group Value Set:
.... previousProcedures.hasPreviousProcedure Has previous procedure 0..1 coding Value Set:
Options: 3 options
.... previousProcedures.procedureType Type of previous procedure 0..1 coding Enable When: previousProcedures.hasPreviousProcedure = Yes (qualifier value) (SNOMED CT#373066001)
Value Set:
Options: 4 options
.... previousProcedures.procedureDate Procedure date 0..1 date Enable When: previousProcedures.hasPreviousProcedure = Yes (qualifier value) (SNOMED CT#373066001)
Value Set:
... colposcopyData Colposcopy examination data 0..1 group Value Set:
.... colposcopyData.colposcopyStatus Colposcopy status 0..1 coding Value Set:
Options: 2 options
.... colposcopyData.swedeScore Swede score (0-10) 0..1 integer Value Set:
.... colposcopyData.adequacy Adequacy of colposcopy 0..1 coding Value Set:
Options: 2 options
.... biopsyProcedure.procedureType Procedure type 0..1 coding Value Set:
Options: 4 options
... biopsySites Biopsy site description 0..1 group Value Set:
.... biopsySites.containers Container 0..* group Value Set:
..... biopsySites.containers.biopsySite Biopsy site 0..1 coding Value Set:
Options: 5 options
..... biopsySites.containers.anatomicalNotes Anatomical notes 0..1 text Value Set:
..... biopsySites.containers.numberOfFragments Number of fragments 0..1 integer Value Set:
... macroscopic Macroscopic examination 0..1 group Value Set:
.... macroscopic.tissueSizeX Tissue size X (mm) 0..1 decimal Value Set:
.... macroscopic.tissueSizeY Tissue size Y (mm) 0..1 decimal Value Set:
.... macroscopic.tissueSizeZ Tissue size Z (mm) 0..1 decimal Value Set:
.... macroscopic.ectocervixSizeX Ectocervix size X (mm) 0..1 decimal Value Set:
.... macroscopic.ectocervixSizeY Ectocervix size Y (mm) 0..1 decimal Value Set:
.... macroscopic.otherFindingsSize Other findings / size 0..1 text Value Set:
.... macroscopic.notes Notes 0..1 text Value Set:
... microscopic Microscopic examination 0..1 group Value Set:
.... microscopic.description Microscopic description 0..1 text Value Set:
... conclusion Conclusion / Diagnosis 0..1 group Value Set:
.... conclusion.diagnosisCategory Diagnosis category 0..1 coding Value Set:
Options: 13 options
... grade Histological grade 0..1 group Enable When:
Value Set:
.... grade.grade Grade 0..1 coding Value Set:
Options: 4 options
... tumorSize Tumor size 0..1 group Enable When:
Value Set:
.... tumorSize.horizontal Horizontal extent (mm) 0..1 decimal Value Set:
.... tumorSize.depth Depth of invasion (mm) 0..1 decimal Value Set:
... pLVI Lymphovascular invasion (pLVI) 0..1 group Value Set:
.... pLVI.status pLVI status 0..1 coding Value Set:
Options: 3 options
... margins Surgical margins 0..1 group Enable When:
Value Set:
.... margins.marginStatus Margin status 0..1 coding Value Set:
Options: 5 options
... tnm TNM staging 0..1 group Value Set:
.... tnm.pT pT stage 0..1 coding Value Set:
Options: 7 options
.... tnm.pR pR stage 0..1 coding Value Set:
Options: 4 options
.... tnm.icd10Code ICD-10 code 0..1 string Value Set:
.... tnm.icdOCode ICD-O code 0..1 string Value Set:
.... tnm.snomedCode SNOMED CT code 0..1 string Value Set:
... conductedBy Conducted by 0..1 group Value Set:
.... conductedBy.conductedName Name 1..1 string Value Set:
.... conductedBy.conductedSurname Surname 1..1 string Value Set:
.... conductedBy.conductedPressNumber Medical press number 1..1 string Value Set:
.... conductedBy.responseDate Response date 0..1 dateTime Value Set:
... confirmedBy Confirmed by 0..1 group Value Set:
.... confirmedBy.confirmedName Name 1..1 string Value Set:
.... confirmedBy.confirmedSurname Surname 1..1 string Value Set:
.... confirmedBy.confirmedPressNumber Medical press number 1..1 string Value Set:
.... confirmedBy.confirmationDate Confirmation date 0..1 dateTime Value Set:

doco Documentation for this format

Options Sets

Answer options for previousProcedures.hasPreviousProcedure

  • http://snomed.info/sct#373067005 ("No (qualifier value)")
  • http://snomed.info/sct#373066001 ("Yes (qualifier value)")
  • http://snomed.info/sct#261665006 ("Unknown (qualifier value)")

Answer options for previousProcedures.procedureType

  • http://snomed.info/sct#50796003 ("Cervical biopsy (procedure)")
  • http://snomed.info/sct#108941001 ("History of cervical conization (situation)")
  • http://snomed.info/sct#125211000011906 ("History of antineoplastic chemotherapy (situation)")
  • http://snomed.info/sct#429479009 ("History of radiation therapy (situation)")

Answer options for colposcopyData.colposcopyStatus

  • http://snomed.info/sct#392003006 ("Colposcopy performed")
  • http://snomed.info/sct#416237000 ("Colposcopy postponed")

Answer options for colposcopyData.adequacy

  • http://snomed.info/sct#125152006 ("Specimen satisfactory for evaluation (finding)")
  • http://snomed.info/sct#125154007 ("Specimen unsatisfactory for evaluation (finding)")

Answer options for biopsyProcedure.procedureType

  • http://snomed.info/sct#51675008 ("Punch biopsy of cervix (procedure)")
  • http://snomed.info/sct#23140002 ("Loop electrosurgical excision procedure of cervix (procedure)")
  • http://snomed.info/sct#54535009 ("Cone biopsy of cervix (procedure)")
  • http://snomed.info/sct#52889002 ("Endocervical curettage (procedure)")

Answer options for biopsySites.containers.biopsySite

  • http://snomed.info/sct#127900007 ("Structure of left superior quadrant of uterine cervix")
  • http://snomed.info/sct#127902004 ("Structure of right superior quadrant of uterine cervix")
  • http://snomed.info/sct#127901006 ("Structure of right inferior quadrant of uterine cervix")
  • http://snomed.info/sct#127899002 ("Structure of left inferior quadrant of uterine cervix")
  • http://snomed.info/sct#56739004 ("Structure of cervical canal of uterus")

Answer options for conclusion.diagnosisCategory

  • http://snomed.info/sct#30389008 ("Normal tissue (finding)")
  • http://snomed.info/sct#125513006 ("Reactive cellular changes (morphologic abnormality)")
  • http://snomed.info/sct#125154007 ("Specimen unsatisfactory for evaluation (finding)")
  • http://snomed.info/sct#400002005 ("Squamous intraepithelial neoplasia grade 1 (morphologic abnormality)")
  • http://snomed.info/sct#400049009 ("Squamous intraepithelial neoplasia grade 2 (morphologic abnormality)")
  • http://snomed.info/sct#1162893000 ("Squamous cell carcinoma in situ (morphologic abnormality)")
  • http://snomed.info/sct#12478003 ("Squamous cell carcinoma, microinvasive (morphologic abnormality)")
  • http://snomed.info/sct#1157180003 ("Human papillomavirus-associated adenocarcinoma in situ (morphologic abnormality)")
  • http://snomed.info/sct#1157186009 ("Human papillomavirus-independent adenocarcinoma in situ (morphologic abnormality)")
  • http://snomed.info/sct#783212001 ("Human papillomavirus positive squamous cell carcinoma (morphologic abnormality)")
  • http://snomed.info/sct#783213006 ("Human papillomavirus negative squamous cell carcinoma (morphologic abnormality)")
  • http://snomed.info/sct#1162767002 ("Squamous cell carcinoma (morphologic abnormality)")
  • http://snomed.info/sct#1187332001 ("Adenocarcinoma (morphologic abnormality)")

Answer options for grade.grade

  • http://snomed.info/sct#1228848004 ("American Joint Committee on Cancer grade G1 (qualifier value)")
  • http://snomed.info/sct#1228850007 ("American Joint Committee on Cancer grade G2 (qualifier value)")
  • http://snomed.info/sct#1228851006 ("American Joint Committee on Cancer grade G3 (qualifier value)")
  • http://snomed.info/sct#1228845001 ("American Joint Committee on Cancer grade GX (qualifier value)")

Answer options for pLVI.status

  • http://snomed.info/sct#373066001 ("Yes (qualifier value)")
  • http://snomed.info/sct#373067005 ("No (qualifier value)")
  • http://snomed.info/sct#261665006 ("Unknown (qualifier value)")

Answer options for margins.marginStatus

  • http://snomed.info/sct#310342002 ("Excision - clear margin (finding)")
  • http://snomed.info/sct#396256001 ("Surgical exocervical margin involved by malignant neoplasm (finding)")
  • http://snomed.info/sct#396246000 ("Surgical endocervical margin involved by malignant neoplasm (finding)")
  • http://snomed.info/sct#395544008 ("Surgical deep margin involved by malignant neoplasm (finding)")
  • http://snomed.info/sct#395537004 ("Involvement of surgical margins by the tumor cannot be assessed (finding)")

Answer options for tnm.pT

  • http://snomed.info/sct#1228950008 ("American Joint Committee on Cancer pTX (qualifier value)")
  • http://snomed.info/sct#1228951007 ("American Joint Committee on Cancer pT0 (qualifier value)")
  • http://snomed.info/sct#1228953005 ("American Joint Committee on Cancer pTis (qualifier value)")
  • http://snomed.info/sct#1228960004 ("American Joint Committee on Cancer pT1a1 (qualifier value)")
  • http://snomed.info/sct#1228961000 ("American Joint Committee on Cancer pT1a2 (qualifier value)")
  • http://snomed.info/sct#1229844006 ("American Joint Committee on Cancer pT1b1 (qualifier value)")
  • http://snomed.info/sct#1229845007 ("American Joint Committee on Cancer pT1b2 (qualifier value)")

Answer options for tnm.pR

  • http://snomed.info/sct#1222641001 ("American Joint Committee on Cancer RX (qualifier value)")
  • http://snomed.info/sct#1222638005 ("American Joint Committee on Cancer R0 (qualifier value)")
  • http://snomed.info/sct#1222639002 ("American Joint Committee on Cancer R1 (qualifier value)")
  • http://snomed.info/sct#1222640000 ("American Joint Committee on Cancer R2 (qualifier value)")

Language: en

Referral to perform pathology test

  • linkId: referral
  • Answers:

Personal code*

  • linkId: referral.personalCode
  • Answers:

Name*

  • linkId: referral.name
  • Answers:

Surname*

  • linkId: referral.surname
  • Answers:

Date of birth

  • linkId: referral.dateOfBirth
  • Answers:

Clinical diagnosis (ICD-10 code with name)

  • linkId: referral.clinicalDiagnosis
  • Answers:

Previous procedures history

  • linkId: previousProcedures
  • Answers:

Has previous procedure

Type of previous procedure

Procedure date

  • linkId: previousProcedures.procedureDate
  • Enable When: todo
  • Answers:

Colposcopy examination data

  • linkId: colposcopyData
  • Answers:

Colposcopy status

Swede score (0-10)

  • linkId: colposcopyData.swedeScore
  • Answers:

Adequacy of colposcopy

Nature of operation/procedure

  • linkId: biopsyProcedure
  • Answers:

Procedure type

Biopsy site description

  • linkId: biopsySites
  • Answers:

Container

  • linkId: biopsySites.containers
  • Answers:

Biopsy site

Anatomical notes

  • linkId: biopsySites.containers.anatomicalNotes
  • Answers:

Number of fragments

  • linkId: biopsySites.containers.numberOfFragments
  • Answers:

Macroscopic examination

  • linkId: macroscopic
  • Answers:

Tissue size X (mm)

  • linkId: macroscopic.tissueSizeX
  • Answers:

Tissue size Y (mm)

  • linkId: macroscopic.tissueSizeY
  • Answers:

Tissue size Z (mm)

  • linkId: macroscopic.tissueSizeZ
  • Answers:

Ectocervix size X (mm)

  • linkId: macroscopic.ectocervixSizeX
  • Answers:

Ectocervix size Y (mm)

  • linkId: macroscopic.ectocervixSizeY
  • Answers:

Other findings / size

  • linkId: macroscopic.otherFindingsSize
  • Answers:

Notes

  • linkId: macroscopic.notes
  • Answers:

Microscopic examination

  • linkId: microscopic
  • Answers:

Microscopic description

  • linkId: microscopic.description
  • Answers:

Conclusion / Diagnosis

  • linkId: conclusion
  • Answers:

Diagnosis category

Histological grade

  • linkId: grade
  • Enable When: todo
  • Answers:

Grade

Tumor size

  • linkId: tumorSize
  • Enable When: todo
  • Answers:

Horizontal extent (mm)

  • linkId: tumorSize.horizontal
  • Answers:

Depth of invasion (mm)

  • linkId: tumorSize.depth
  • Answers:

Lymphovascular invasion (pLVI)

  • linkId: pLVI
  • Answers:

pLVI status

Surgical margins

  • linkId: margins
  • Enable When: todo
  • Answers:

Margin status

TNM staging

  • linkId: tnm
  • Answers:

pT stage

pR stage

ICD-10 code

  • linkId: tnm.icd10Code
  • Answers:

ICD-O code

  • linkId: tnm.icdOCode
  • Answers:

SNOMED CT code

  • linkId: tnm.snomedCode
  • Answers:

Conducted by

  • linkId: conductedBy
  • Answers:

Name*

  • linkId: conductedBy.conductedName
  • Answers:

Surname*

  • linkId: conductedBy.conductedSurname
  • Answers:

Medical press number*

  • linkId: conductedBy.conductedPressNumber
  • Answers:

Response date

  • linkId: conductedBy.responseDate
  • Answers:

Confirmed by

  • linkId: confirmedBy
  • Answers:

Name*

  • linkId: confirmedBy.confirmedName
  • Answers:

Surname*

  • linkId: confirmedBy.confirmedSurname
  • Answers:

Medical press number*

  • linkId: confirmedBy.confirmedPressNumber
  • Answers:

Confirmation date

  • linkId: confirmedBy.confirmationDate
  • Answers:

Language: en

LinkIDDescription & Constraintsdoco
.. referral Value Set:
... referral.personalCode Value Set:
... referral.name Value Set:
... referral.surname Value Set:
... referral.clinicalDiagnosis Value Set:
.. previousProcedures Value Set:
... previousProcedures.hasPreviousProcedure Value Set:
Options: 3 options
... previousProcedures.procedureType Enable When: Not done yet
Value Set:
Options: 4 options
... previousProcedures.procedureDate Enable When: Not done yet
Value Set:
.. colposcopyData Value Set:
... colposcopyData.colposcopyStatus Value Set:
Options: 2 options
... colposcopyData.swedeScore Value Set:
... colposcopyData.adequacy Value Set:
Options: 2 options
.. biopsyProcedure Value Set:
... biopsyProcedure.procedureType Value Set:
Options: 4 options
.. biopsySites Value Set:
... biopsySites.containers Value Set:
.... biopsySites.containers.biopsySite Value Set:
Options: 5 options
.... biopsySites.containers.anatomicalNotes Value Set:
.... biopsySites.containers.numberOfFragments Value Set:
.. macroscopic Value Set:
... macroscopic.tissueSizeX Value Set:
... macroscopic.tissueSizeY Value Set:
... macroscopic.tissueSizeZ Value Set:
... macroscopic.ectocervixSizeX Value Set:
... macroscopic.ectocervixSizeY Value Set:
... macroscopic.otherFindingsSize Value Set:
... macroscopic.notes Value Set:
.. microscopic Value Set:
... microscopic.description Value Set:
.. conclusion Value Set:
... conclusion.diagnosisCategory Value Set:
Options: 13 options
.. grade Enable When: Not done yet
Value Set:
... grade.grade Value Set:
Options: 4 options
.. tumorSize Enable When: Not done yet
Value Set:
... tumorSize.horizontal Value Set:
... tumorSize.depth Value Set:
.. pLVI Value Set:
... pLVI.status Value Set:
Options: 3 options
.. margins Enable When: Not done yet
Value Set:
... margins.marginStatus Value Set:
Options: 5 options
.. tnm Value Set:
... tnm.pT Value Set:
Options: 7 options
... tnm.pR Value Set:
Options: 4 options
... tnm.icd10Code Value Set:
... tnm.icdOCode Value Set:
... tnm.snomedCode Value Set:
.. conductedBy Value Set:
... conductedBy.conductedName Value Set:
... conductedBy.conductedSurname Value Set:
... conductedBy.conductedPressNumber Value Set:
... conductedBy.responseDate Value Set:
.. confirmedBy Value Set:
... confirmedBy.confirmedName Value Set:
... confirmedBy.confirmedSurname Value Set:
... confirmedBy.confirmedPressNumber Value Set:
... confirmedBy.confirmationDate Value Set:

doco Documentation for this format

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Responses for this Questionnaire