Lithuanian Colorectal Cancer Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Colorectal 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-colorectal/ and changes regularly. See the Directory of published versions

Pavyzdys QuestionnaireResponse: QuestionnaireResponse: ESPBI Colonoscopy (example)

Lithuanian

Language: en

LinkIDTextDefinitionAnswerdoco
.. questionnaireresponse-colonoscopy-espbi-exampleQuestionnaire:ESPBI Colonoscopy Form
... basicInfoBasic descriptive part
.... basicInfo.postponedColonoscopyWas colonoscopy postponed for screening?false
.... basicInfo.anesthesiaAnesthesiaSNOMED CT: 398166005 (Performed)
.... basicInfo.videoColonoscopeVideo colonoscope used?SNOMED CT: 373066001 (Yes)
.... basicInfo.withdrawalTimeWithdrawal time (minutes)8
.... basicInfo.procedureDateProcedure date2026-03-12T10:00:00+02:00
... bowelPrepBowel preparation assessment
.... bowelPrep.prepQualityBowel preparation quality adequate?SNOMED CT: 373066001 (Yes)
.... bowelPrep.bbpsRightBBPS Right colon / ascending (0-3)2
.... bowelPrep.bbpsTransverseBBPS Transverse colon (0-3)2
.... bowelPrep.bbpsLeftBBPS Left colon / descending + sigmoid (0-3)3
.... bowelPrep.totalBbpsTotal BBPS score (0-9)7
.... bowelPrep.dietaryRecommendationsWere dietary recommendations given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.splitDoseWas split-dose protocol used?SNOMED CT: 373066001 (Yes)
.... bowelPrep.writtenInfoWas written information about preparation given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.usedPreparationsUsed preparations for bowel preparationSNOMED CT: 712567003 (Macrogol 4000 (substance))
... scopeReachColonoscope reach
.... scopeReach.reachLocationDeepest point reached by colonoscopeSNOMED CT: 32713005 (Cecum structure)
... polypFindingsPolyp findings
.... polypFindings.polypFoundPolyp found?true
.... polypFindings.locationPolyp locationSNOMED CT: 60184004 (Sigmoid colon structure)
.... polypFindings.sizeMmPolyp size (mm)8
.... polypFindings.parisClassificationParis endoscopic classification[not stated]: (IIa Slightly elevated)
.... polypFindings.niceClassificationNICE classification[not stated]: (Type II (Adenoma))
.... polypFindings.predictedHistologyPredicted histology[not stated]: (Adenoma)
.... polypFindings.locationSideLocation side[not stated]: (Left side)
.... polypFindings.accessDifficultyAccess difficulty[not stated]: (Easy)
.... polypFindings.smsaScoreSMSA total score5
.... polypFindings.smsaLevelSMSA level[not stated]: (Level 1 (4-5 points))
.... polypFindings.polypRemovedWas polyp removed?SNOMED CT: 373066001 (Yes)
.... polypFindings.removalMethodRemoval method[not stated]: (Cold snare)
.... polypFindings.complicationAfterRemovalComplication after polyp removal?SNOMED CT: 373067005 (No)
.... polypFindings.allPolypsRemovedSimultaneouslyAll polyps removed simultaneously?SNOMED CT: 373066001 (Yes)
.... polypFindings.sentForHistologySent for histological examination?SNOMED CT: 373066001 (Yes)
... tumorFindingsTumor findings
.... tumorFindings.tumorFoundTumor found?false
... complicationsComplications after colonoscopy
.... complications.complicationPresenceWere there complications?SNOMED CT: 373067005 (No)
... conclusionsFinal conclusions
.... conclusions.conclusionConclusion[not stated]: (Polyps found)
.... conclusions.conclusionNotesConclusion notesSingle 8mm adenomatous polyp in the sigmoid colon, removed with cold snare. No other pathology detected.
... recommendationsFollow-up recommendations
.... recommendations.nextColonoscopyRecommended interval for next colonoscopy[not stated]: (3 years)
.... recommendations.additionalNotesAdditional notesPolyp sent for histological examination. Patient informed about the follow-up plan.
... signaturesSignatures
.... signatures.examinerNameExaminer first nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examDateExamination date2026-03-12T14:30:00+02:00

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