Lithuanian Laboratory Implementation Guide
0.0.1 - ci-build
Lithuanian Laboratory Implementation Guide
0.0.1 - ci-build
Lithuanian Laboratory 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-lab/ and changes regularly. See the Directory of published versions
{
"resourceType" : "Composition",
"id" : "composition-pathology-example",
"meta" : {
"profile" : [
🔗 "https://hl7.lt/fhir/lab/StructureDefinition/pathology-composition-lt-lab"
]
},
"language" : "en",
"text" : {
"status" : "generated",
"div" : "<div xml:lang=\"en\" lang=\"en\"><hr/><p><b>English</b></p><hr/><p class=\"res-header-id\"><b>Generated Narrative: Composition composition-pathology-example</b></p><a name=\"composition-pathology-example\"> </a><a name=\"hccomposition-pathology-example\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-pathology-composition-lt-lab.html\">Composition: Pathology Document (LT Lab)</a></p></div><p><b>identifier</b>: <code>http://hospital.lt/sid/composition-number</code>/4540-baab-7a5d0877428f-93468-45y72547</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 371528001}\">Pathology report (record artifact)</span></p><p><b>category</b>: <span title=\"Codes:{http://loinc.org 26436-6}\">Laboratory Studies (set)</span></p><p><b>date</b>: 2022-10-25 14:30:00+0100</p><p><b>author</b>: <a href=\"Practitioner-practitioner-example.html\">Practitioner Registrar</a></p><p><b>title</b>: Histological examination of the breast tissue</p><h3>Attesters</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">legal</span></td><td>2022-10-25 14:30:00+0100</td><td><a href=\"Organization-organization-example.html\">Organization Vilnius Heart Clinic</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-organization-example.html\">Organization Vilnius Heart Clinic</a></p></div>"
},
"identifier" : [
{
"system" : "http://hospital.lt/sid/composition-number",
"value" : "4540-baab-7a5d0877428f-93468-45y72547"
}
],
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "371528001",
"display" : "Pathology report (record artifact)"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "26436-6",
"display" : "Laboratory Studies (set)"
}
]
}
],
"subject" : [
{
🔗 "reference" : "Patient/patient-example"
}
],
"date" : "2022-10-25T14:30:00+01:00",
"author" : [
{
🔗 "reference" : "Practitioner/practitioner-example"
}
],
"title" : "Histological examination of the breast tissue",
"attester" : [
{
"mode" : {
"coding" : [
{
"code" : "legal"
}
]
},
"time" : "2022-10-25T14:30:00+01:00",
"party" : {
🔗 "reference" : "Organization/organization-example"
}
}
],
"custodian" : {
🔗 "reference" : "Organization/organization-example"
},
"section" : [
{
"title" : "Pre-Analytic (Clinical Context)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "22636-5",
"display" : "Pathology report relevant history Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Information collected before laboratory processing: pathology service requests (breast histopathology and prostate pathway), the biopsy procedure, and submitted breast specimens that identify what entered the laboratory.</p></div>"
},
"section" : [
{
"title" : "Breast histopathology order",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Service request for breast histopathology: ordered examination, time frame, and clinical question (e.g. suspicion of malignancy).</p></div>"
},
"entry" : [
{
🔗 "reference" : "ServiceRequest/servicerequest-pathology-order-example"
}
]
},
{
"title" : "Prostate pathology order",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Service request for prostate-related pathology (e.g. screening or diagnostic follow-up) using a PathologyProcedure code.</p></div>"
},
"entry" : [
{
🔗 "reference" : "ServiceRequest/servicerequest-pathology-prostate-order-example"
}
]
},
{
"title" : "Breast biopsy procedure",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Procedure performed to obtain breast tissue for histology, including timing and anatomical site.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Procedure/procedure-breast-biopsy-example"
}
]
},
{
"title" : "Submitted specimen — right breast",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Specimen from the right breast: identifiers and traceability from collection to the laboratory.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Specimen/specimen-right-breast-example"
}
]
},
{
"title" : "Submitted specimen — left breast",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Specimen from the left breast: identifiers and traceability from collection to the laboratory.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Specimen/specimen-left-breast-example"
}
]
}
]
},
{
"title" : "Macro (Macroscopic Examination)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "74574-5",
"display" : "Macroscopic observation [Interpretation] in Specimen Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Gross examination: dimensions and weight of tissue, whether the specimen is adequate for diagnosis, preparation of embedded blocks, and laboratory histology processing.</p></div>"
},
"section" : [
{
"title" : "Gross specimen measurements",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Macroscopic measurements of the specimen (largest dimension, orthogonal dimensions, weight, lymph node count when applicable).</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-specimen-measurement-example"
}
]
},
{
"title" : "Specimen adequacy",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Assessment that the received material is satisfactory for histopathological evaluation.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-specimen-adequacy-example"
}
]
},
{
"title" : "Paraffin tissue block",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Embedded tissue block derived from the parent specimen for sectioning and slides.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Specimen/specimen-block-1-example"
}
]
},
{
"title" : "Histology laboratory procedure",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Laboratory histologic processing step (e.g. preparation after grossing) on the documented date.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Procedure/procedure-histology-example"
}
]
}
]
},
{
"title" : "Micro (Microscopic Examination)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "660-1",
"display" : "Microscopic observation [Identifier] in Specimen by Dark field examination"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Microscopic findings: tumour pattern and extent, size on slide, and immunohistochemistry for hormone receptors and HER2 where indicated.</p></div>"
},
"section" : [
{
"title" : "Tumour characterisation (observable)",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Structured description of neoplasm focality, type, location, nodules, and extent.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-tumor-observable-example"
}
]
},
{
"title" : "Tumour size (dimensions)",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Measured tumour dimensions including largest diameter and further axes.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-tumor-measurement-example"
}
]
},
{
"title" : "Oestrogen receptor (ER) status",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Immunohistochemical assessment of oestrogen receptor expression in tissue.</p></div>"
},
"entry" : [
{
"reference" : "Observation/observation-estrogen-status"
}
]
},
{
"title" : "Progesterone receptor (PR) status",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Immunohistochemical assessment of progesterone receptor expression in tissue.</p></div>"
},
"entry" : [
{
"reference" : "Observation/observation-progesterone-status"
}
]
},
{
"title" : "HER2 receptor status",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>HER2 testing result (e.g. IHC/FISH interpretation) for treatment planning.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-her2-receptor-status-example"
}
]
}
]
},
{
"title" : "Synthesis (Conclusion/Integrated Diagnosis)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "22637-3",
"display" : "Pathology report final diagnosis Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Final integrated output: the signed diagnostic report with narrative conclusion, and—where staging applies—a structured cancer Condition with TNM and morphology.</p></div>"
},
"section" : [
{
"title" : "Diagnostic report (signed)",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Authoritative pathology diagnostic report linking specimens, key results, and overall conclusion for the case.</p></div>"
},
"entry" : [
{
🔗 "reference" : "DiagnosticReport/diagnosticreport-pathology-report-example"
}
]
},
{
"title" : "Example: prostate cancer stage (Condition)",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Illustrative Condition resource for prostate cancer with pathological T and clinical N/M categories and ICD-O-3 morphology—shown here as a separate example of staging structure in this implementation guide.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Condition/condition-prostate-cancer-example"
}
]
}
]
}
]
}