{ "resourceType" : "QuestionnaireResponse", "id" : "qr-cervical-histology-espbi-example", "language" : "lt", "text" : { "status" : "generated", "div" : "

Lithuanian

Generated Narrative: QuestionnaireResponse qr-cervical-histology-espbi-example

Language: en

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LinkIDTextDefinitionAnswer\"doco\"
\".\"\".\" qr-cervical-histology-espbi-exampleQuestionnaire:Cervical Histopathological Examination – ESPBI Form
\".\"\".\"\".\" referralReferral to perform pathology test
\".\"\".\"\".\"\".\" referral.personalCodePersonal code48501019999
\".\"\".\"\".\"\".\" referral.nameNameJanette
\".\"\".\"\".\"\".\" referral.surnameSurnamePetrauskaite
\".\"\".\"\".\"\".\" referral.dateOfBirthDate of birth1985-01-01
\".\"\".\"\".\"\".\" referral.clinicalDiagnosisClinical diagnosis (ICD-10 code with name)N87.1 Moderate cervical dysplasia
\".\"\".\"\".\" previousProceduresPrevious procedures history
\".\"\".\"\".\"\".\" previousProcedures.hasPreviousProcedureHas previous procedureSNOMED CT: 373066001 (Yes (qualifier value))
\".\"\".\"\".\"\".\" previousProcedures.procedureTypeType of previous procedureSNOMED CT: 50796003 (Cervical biopsy (procedure))
\".\"\".\"\".\"\".\" previousProcedures.procedureDateProcedure date2024-11-20
\".\"\".\"\".\" colposcopyDataColposcopy examination data
\".\"\".\"\".\"\".\" colposcopyData.colposcopyStatusColposcopy statusSNOMED CT: 392003006 (Colposcopy performed)
\".\"\".\"\".\"\".\" colposcopyData.swedeScoreSwede score (0-10)7
\".\"\".\"\".\"\".\" colposcopyData.adequacyAdequacy of colposcopySNOMED CT: 125152006 (Specimen satisfactory for evaluation (finding))
\".\"\".\"\".\" biopsyProcedureNature of operation/procedure
\".\"\".\"\".\"\".\" biopsyProcedure.procedureTypeProcedure typeSNOMED CT: 54535009 (Cone biopsy of cervix (procedure))
\".\"\".\"\".\" biopsySitesBiopsy site description
\".\"\".\"\".\"\".\" biopsySites.containersContainer
\".\"\".\"\".\"\".\"\".\" biopsySites.containers.biopsySiteBiopsy siteSNOMED CT: 127900007 (Structure of left superior quadrant of uterine cervix)
\".\"\".\"\".\"\".\"\".\" biopsySites.containers.anatomicalNotesAnatomical notesCone biopsy specimen from transformation zone, left superior quadrant
\".\"\".\"\".\"\".\"\".\" biopsySites.containers.numberOfFragmentsNumber of fragments1
\".\"\".\"\".\" macroscopicMacroscopic examination
\".\"\".\"\".\"\".\" macroscopic.tissueSizeXTissue size X (mm)18
\".\"\".\"\".\"\".\" macroscopic.tissueSizeYTissue size Y (mm)15
\".\"\".\"\".\"\".\" macroscopic.tissueSizeZTissue size Z (mm)12
\".\"\".\"\".\"\".\" macroscopic.ectocervixSizeXEctocervix size X (mm)16
\".\"\".\"\".\"\".\" macroscopic.ectocervixSizeYEctocervix size Y (mm)14
\".\"\".\"\".\"\".\" macroscopic.notesNotesCone biopsy specimen, grey-white tissue, well-oriented with ink marking at 12 o'clock position
\".\"\".\"\".\" microscopicMicroscopic examination
\".\"\".\"\".\"\".\" microscopic.descriptionMicroscopic descriptionSections show high-grade squamous intraepithelial neoplasia (CIN2) involving the transformation zone. The dysplastic epithelium extends through the upper two-thirds of the squamous epithelium with increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and mitotic figures. No stromal invasion identified. Endocervical glands are unremarkable.
\".\"\".\"\".\" conclusionConclusion / Diagnosis
\".\"\".\"\".\"\".\" conclusion.diagnosisCategoryDiagnosis categorySNOMED CT: 400049009 (Squamous intraepithelial neoplasia grade 2 (morphologic abnormality))
\".\"\".\"\".\" gradeHistological grade
\".\"\".\"\".\"\".\" grade.gradeGradeSNOMED CT: 1228850007 (American Joint Committee on Cancer grade G2 (qualifier value))
\".\"\".\"\".\" pLVILymphovascular invasion (pLVI)
\".\"\".\"\".\"\".\" pLVI.statuspLVI statusSNOMED CT: 373067005 (No (qualifier value))
\".\"\".\"\".\" marginsSurgical margins
\".\"\".\"\".\"\".\" margins.marginStatusMargin statusSNOMED CT: 310342002 (Excision - clear margin (finding))
\".\"\".\"\".\" tnmTNM staging
\".\"\".\"\".\"\".\" tnm.pTpT stageSNOMED CT: 1228953005 (American Joint Committee on Cancer pTis (qualifier value))
\".\"\".\"\".\"\".\" tnm.pRpR stageSNOMED CT: 1222638005 (American Joint Committee on Cancer R0 (qualifier value))
\".\"\".\"\".\"\".\" tnm.icd10CodeICD-10 codeD06.9
\".\"\".\"\".\"\".\" tnm.snomedCodeSNOMED CT code400049009
\".\"\".\"\".\" conductedByConducted by
\".\"\".\"\".\"\".\" conductedBy.conductedNameNamePetras
\".\"\".\"\".\"\".\" conductedBy.conductedSurnameSurnameKazlauskas
\".\"\".\"\".\"\".\" conductedBy.conductedPressNumberMedical press numberMED-LT-54321
\".\"\".\"\".\"\".\" conductedBy.responseDateResponse date2025-04-15T14:30:00+03:00
\".\"\".\"\".\" confirmedByConfirmed by
\".\"\".\"\".\"\".\" confirmedBy.confirmedNameNameRuta
\".\"\".\"\".\"\".\" confirmedBy.confirmedSurnameSurnameJonaite
\".\"\".\"\".\"\".\" confirmedBy.confirmedPressNumberMedical press numberMED-LT-67890
\".\"\".\"\".\"\".\" confirmedBy.confirmationDateConfirmation date2025-04-16T09:00:00+03:00

\"doco\" Documentation for this format
" }, "questionnaire" : "https://hl7.lt/fhir/cervical/Questionnaire/questionnaire-cervical-histology-espbi", "status" : "completed", "subject" : { "reference" : "Patient/patient-female-example" }, "authored" : "2025-04-15T14:30:00+03:00", "author" : { "reference" : "Practitioner/practitioner-example" }, "item" : [{ "linkId" : "referral", "text" : "Referral to perform pathology test", "item" : [{ "linkId" : "referral.personalCode", "text" : "Personal code", "answer" : [{ "valueString" : "48501019999" }] }, { "linkId" : "referral.name", "text" : "Name", "answer" : [{ "valueString" : "Janette" }] }, { "linkId" : "referral.surname", "text" : "Surname", "answer" : [{ "valueString" : "Petrauskaite" }] }, { "linkId" : "referral.dateOfBirth", "text" : "Date of birth", "answer" : [{ "valueDate" : "1985-01-01" }] }, { "linkId" : "referral.clinicalDiagnosis", "text" : "Clinical diagnosis (ICD-10 code with name)", "answer" : [{ "valueString" : "N87.1 Moderate cervical dysplasia" }] }] }, { "linkId" : "previousProcedures", "text" : "Previous procedures history", "item" : [{ "linkId" : "previousProcedures.hasPreviousProcedure", "text" : "Has previous procedure", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "373066001", "display" : "Yes (qualifier value)" } }] }, { "linkId" : "previousProcedures.procedureType", "text" : "Type of previous procedure", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "50796003", "display" : "Cervical biopsy (procedure)" } }] }, { "linkId" : "previousProcedures.procedureDate", "text" : "Procedure date", "answer" : [{ "valueDate" : "2024-11-20" }] }] }, { "linkId" : "colposcopyData", "text" : "Colposcopy examination data", "item" : [{ "linkId" : "colposcopyData.colposcopyStatus", "text" : "Colposcopy status", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "392003006", "display" : "Colposcopy performed" } }] }, { "linkId" : "colposcopyData.swedeScore", "text" : "Swede score (0-10)", "answer" : [{ "valueInteger" : 7 }] }, { "linkId" : "colposcopyData.adequacy", "text" : "Adequacy of colposcopy", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "125152006", "display" : "Specimen satisfactory for evaluation (finding)" } }] }] }, { "linkId" : "biopsyProcedure", "text" : "Nature of operation/procedure", "item" : [{ "linkId" : "biopsyProcedure.procedureType", "text" : "Procedure type", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "54535009", "display" : "Cone biopsy of cervix (procedure)" } }] }] }, { "linkId" : "biopsySites", "text" : "Biopsy site description", "item" : [{ "linkId" : "biopsySites.containers", "text" : "Container", "item" : [{ "linkId" : "biopsySites.containers.biopsySite", "text" : "Biopsy site", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "127900007", "display" : "Structure of left superior quadrant of uterine cervix" } }] }, { "linkId" : "biopsySites.containers.anatomicalNotes", "text" : "Anatomical notes", "answer" : [{ "valueString" : "Cone biopsy specimen from transformation zone, left superior quadrant" }] }, { "linkId" : "biopsySites.containers.numberOfFragments", "text" : "Number of fragments", "answer" : [{ "valueInteger" : 1 }] }] }] }, { "linkId" : "macroscopic", "text" : "Macroscopic examination", "item" : [{ "linkId" : "macroscopic.tissueSizeX", "text" : "Tissue size X (mm)", "answer" : [{ "valueDecimal" : 18 }] }, { "linkId" : "macroscopic.tissueSizeY", "text" : "Tissue size Y (mm)", "answer" : [{ "valueDecimal" : 15 }] }, { "linkId" : "macroscopic.tissueSizeZ", "text" : "Tissue size Z (mm)", "answer" : [{ "valueDecimal" : 12 }] }, { "linkId" : "macroscopic.ectocervixSizeX", "text" : "Ectocervix size X (mm)", "answer" : [{ "valueDecimal" : 16 }] }, { "linkId" : "macroscopic.ectocervixSizeY", "text" : "Ectocervix size Y (mm)", "answer" : [{ "valueDecimal" : 14 }] }, { "linkId" : "macroscopic.notes", "text" : "Notes", "answer" : [{ "valueString" : "Cone biopsy specimen, grey-white tissue, well-oriented with ink marking at 12 o'clock position" }] }] }, { "linkId" : "microscopic", "text" : "Microscopic examination", "item" : [{ "linkId" : "microscopic.description", "text" : "Microscopic description", "answer" : [{ "valueString" : "Sections show high-grade squamous intraepithelial neoplasia (CIN2) involving the transformation zone. The dysplastic epithelium extends through the upper two-thirds of the squamous epithelium with increased nuclear-to-cytoplasmic ratio, nuclear hyperchromasia, and mitotic figures. No stromal invasion identified. Endocervical glands are unremarkable." }] }] }, { "linkId" : "conclusion", "text" : "Conclusion / Diagnosis", "item" : [{ "linkId" : "conclusion.diagnosisCategory", "text" : "Diagnosis category", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "400049009", "display" : "Squamous intraepithelial neoplasia grade 2 (morphologic abnormality)" } }] }] }, { "linkId" : "grade", "text" : "Histological grade", "item" : [{ "linkId" : "grade.grade", "text" : "Grade", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1228850007", "display" : "American Joint Committee on Cancer grade G2 (qualifier value)" } }] }] }, { "linkId" : "pLVI", "text" : "Lymphovascular invasion (pLVI)", "item" : [{ "linkId" : "pLVI.status", "text" : "pLVI status", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "373067005", "display" : "No (qualifier value)" } }] }] }, { "linkId" : "margins", "text" : "Surgical margins", "item" : [{ "linkId" : "margins.marginStatus", "text" : "Margin status", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "310342002", "display" : "Excision - clear margin (finding)" } }] }] }, { "linkId" : "tnm", "text" : "TNM staging", "item" : [{ "linkId" : "tnm.pT", "text" : "pT stage", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1228953005", "display" : "American Joint Committee on Cancer pTis (qualifier value)" } }] }, { "linkId" : "tnm.pR", "text" : "pR stage", "answer" : [{ "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "1222638005", "display" : "American Joint Committee on Cancer R0 (qualifier value)" } }] }, { "linkId" : "tnm.icd10Code", "text" : "ICD-10 code", "answer" : [{ "valueString" : "D06.9" }] }, { "linkId" : "tnm.snomedCode", "text" : "SNOMED CT code", "answer" : [{ "valueString" : "400049009" }] }] }, { "linkId" : "conductedBy", "text" : "Conducted by", "item" : [{ "linkId" : "conductedBy.conductedName", "text" : "Name", "answer" : [{ "valueString" : "Petras" }] }, { "linkId" : "conductedBy.conductedSurname", "text" : "Surname", "answer" : [{ "valueString" : "Kazlauskas" }] }, { "linkId" : "conductedBy.conductedPressNumber", "text" : "Medical press number", "answer" : [{ "valueString" : "MED-LT-54321" }] }, { "linkId" : "conductedBy.responseDate", "text" : "Response date", "answer" : [{ "valueDateTime" : "2025-04-15T14:30:00+03:00" }] }] }, { "linkId" : "confirmedBy", "text" : "Confirmed by", "item" : [{ "linkId" : "confirmedBy.confirmedName", "text" : "Name", "answer" : [{ "valueString" : "Ruta" }] }, { "linkId" : "confirmedBy.confirmedSurname", "text" : "Surname", "answer" : [{ "valueString" : "Jonaite" }] }, { "linkId" : "confirmedBy.confirmedPressNumber", "text" : "Medical press number", "answer" : [{ "valueString" : "MED-LT-67890" }] }, { "linkId" : "confirmedBy.confirmationDate", "text" : "Confirmation date", "answer" : [{ "valueDateTime" : "2025-04-16T09:00:00+03:00" }] }] }] }