<attester> <mode> <coding> <code value="legal"/> </coding> </mode> <time value="2022-10-25T14:30:00+01:00"/> <party> <reference value="Organization/organization-example"/> </party> </attester> <custodian> <reference value="Organization/organization-example"/> </custodian> <section> <title value="Pre-Analytic (Clinical Context)"/> <code> <coding> <system value="http://loinc.org"/> <code value="22636-5"/> <display value="Pathology report relevant history Narrative"/> </coding> </code> <text> <status value="generated"/><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> </text> <section> <title value="Breast histopathology order"/> <text> <status value="generated"/><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> </text> <entry> <reference value="ServiceRequest/servicerequest-pathology-order-example"/> </entry> </section> <section> <title value="Prostate pathology order"/> <text> <status value="generated"/><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> </text> <entry> <reference value="ServiceRequest/servicerequest-pathology-prostate-order-example"/> </entry> </section> <section> <title value="Breast biopsy procedure"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Procedure performed to obtain breast tissue for histology, including timing and anatomical site.</p></div> </text> <entry> <reference value="Procedure/procedure-breast-biopsy-example"/> </entry> </section> <section> <title value="Submitted specimen — right breast"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Specimen from the right breast: identifiers and traceability from collection to the laboratory.</p></div> </text> <entry> <reference value="Specimen/specimen-right-breast-example"/> </entry> </section> <section> <title value="Submitted specimen — left breast"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Specimen from the left breast: identifiers and traceability from collection to the laboratory.</p></div> </text> <entry> <reference value="Specimen/specimen-left-breast-example"/> </entry> </section> </section> <section> <title value="Macro (Macroscopic Examination)"/> <code> <coding> <system value="http://loinc.org"/> <code value="74574-5"/> <display value="Macroscopic observation [Interpretation] in Specimen Narrative"/> </coding> </code> <text> <status value="generated"/><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> </text> <section> <title value="Gross specimen measurements"/> <text> <status value="generated"/><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> </text> <entry> <reference value="Observation/observation-specimen-measurement-example"/> </entry> </section> <section> <title value="Specimen adequacy"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Assessment that the received material is satisfactory for histopathological evaluation.</p></div> </text> <entry> <reference value="Observation/observation-specimen-adequacy-example"/> </entry> </section> <section> <title value="Paraffin tissue block"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Embedded tissue block derived from the parent specimen for sectioning and slides.</p></div> </text> <entry> <reference value="Specimen/specimen-block-1-example"/> </entry> </section> <section> <title value="Histology laboratory procedure"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Laboratory histologic processing step (e.g. preparation after grossing) on the documented date.</p></div> </text> <entry> <reference value="Procedure/procedure-histology-example"/> </entry> </section> </section> <section> <title value="Micro (Microscopic Examination)"/> <code> <coding> <system value="http://loinc.org"/> <code value="660-1"/> <display value="Microscopic observation [Identifier] in Specimen by Dark field examination"/> </coding> </code> <text> <status value="generated"/><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> </text> <section> <title value="Tumour characterisation (observable)"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Structured description of neoplasm focality, type, location, nodules, and extent.</p></div> </text> <entry> <reference value="Observation/observation-tumor-observable-example"/> </entry> </section> <section> <title value="Tumour size (dimensions)"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Measured tumour dimensions including largest diameter and further axes.</p></div> </text> <entry> <reference value="Observation/observation-tumor-measurement-example"/> </entry> </section> <section> <title value="Oestrogen receptor (ER) status"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Immunohistochemical assessment of oestrogen receptor expression in tissue.</p></div> </text> <entry> <reference value="Observation/observation-estrogen-status"/> </entry> </section> <section> <title value="Progesterone receptor (PR) status"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Immunohistochemical assessment of progesterone receptor expression in tissue.</p></div> </text> <entry> <reference value="Observation/observation-progesterone-status"/> </entry> </section> <section> <title value="HER2 receptor status"/> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>HER2 testing result (e.g. IHC/FISH interpretation) for treatment planning.</p></div> </text> <entry> <reference value="Observation/observation-her2-receptor-status-example"/> </entry> </section> </section> <section> <title value="Synthesis (Conclusion/Integrated Diagnosis)"/> <code> <coding> <system value="http://loinc.org"/> <code value="22637-3"/> <display value="Pathology report final diagnosis Narrative"/> </coding> </code> <text> <status value="generated"/><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> </text> <section> <title value="Diagnostic report (signed)"/> <text> <status value="generated"/><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> </text> <entry> <reference value="DiagnosticReport/diagnosticreport-pathology-report-example"/> </entry> </section> <section> <title value="Example: prostate cancer stage (Condition)"/> <text> <status value="generated"/><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> </text> <entry> <reference value="Condition/condition-prostate-cancer-example"/> </entry> </section> </section> </Composition>

English

Generated Narrative: Composition composition-pathology-example

Language: en

Profile: Composition: Pathology Document (LT Lab)

identifier: http://hospital.lt/sid/composition-number/4540-baab-7a5d0877428f-93468-45y72547

status: Final

type: Pathology report (record artifact)

category: Laboratory Studies (set)

date: 2022-10-25 14:30:00+0100

author: Practitioner Registrar

title: Histological examination of the breast tissue

Attesters

Mode

Time

Party

legal

2022-10-25 14:30:00+0100

Organization Vilnius Heart Clinic

custodian: Organization Vilnius Heart Clinic


  
    
      
      
      
    
  
  
    
  
  
  
    
  
  
  <attester>
    <mode>
      <coding>
        <code value="legal"/>
      </coding>
    </mode>
    <time value="2022-10-25T14:30:00+01:00"/>
    <party>
      <reference value="Organization/organization-example"/>
    </party>
  </attester>
  <custodian>
    <reference value="Organization/organization-example"/>
  </custodian>
  <section>
    <title value="Pre-Analytic (Clinical Context)"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="22636-5"/>
        <display value="Pathology report relevant history Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><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>
    </text>
    <section>
      <title value="Breast histopathology order"/>
      <text>
        <status value="generated"/><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>
      </text>
      <entry>
        <reference value="ServiceRequest/servicerequest-pathology-order-example"/>
      </entry>
    </section>
    <section>
      <title value="Prostate pathology order"/>
      <text>
        <status value="generated"/><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>
      </text>
      <entry>
        <reference value="ServiceRequest/servicerequest-pathology-prostate-order-example"/>
      </entry>
    </section>
    <section>
      <title value="Breast biopsy procedure"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Procedure performed to obtain breast tissue for histology, including timing and anatomical site.</p></div>
      </text>
      <entry>
        <reference value="Procedure/procedure-breast-biopsy-example"/>
      </entry>
    </section>
    <section>
      <title value="Submitted specimen — right breast"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Specimen from the right breast: identifiers and traceability from collection to the laboratory.</p></div>
      </text>
      <entry>
        <reference value="Specimen/specimen-right-breast-example"/>
      </entry>
    </section>
    <section>
      <title value="Submitted specimen — left breast"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Specimen from the left breast: identifiers and traceability from collection to the laboratory.</p></div>
      </text>
      <entry>
        <reference value="Specimen/specimen-left-breast-example"/>
      </entry>
    </section>
  </section>
  <section>
    <title value="Macro (Macroscopic Examination)"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="74574-5"/>
        <display value="Macroscopic observation [Interpretation] in Specimen Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><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>
    </text>
    <section>
      <title value="Gross specimen measurements"/>
      <text>
        <status value="generated"/><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>
      </text>
      <entry>
        <reference value="Observation/observation-specimen-measurement-example"/>
      </entry>
    </section>
    <section>
      <title value="Specimen adequacy"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Assessment that the received material is satisfactory for histopathological evaluation.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-specimen-adequacy-example"/>
      </entry>
    </section>
    <section>
      <title value="Paraffin tissue block"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Embedded tissue block derived from the parent specimen for sectioning and slides.</p></div>
      </text>
      <entry>
        <reference value="Specimen/specimen-block-1-example"/>
      </entry>
    </section>
    <section>
      <title value="Histology laboratory procedure"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Laboratory histologic processing step (e.g. preparation after grossing) on the documented date.</p></div>
      </text>
      <entry>
        <reference value="Procedure/procedure-histology-example"/>
      </entry>
    </section>
  </section>
  <section>
    <title value="Micro (Microscopic Examination)"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="660-1"/>
        <display value="Microscopic observation [Identifier] in Specimen by Dark field examination"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><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>
    </text>
    <section>
      <title value="Tumour characterisation (observable)"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Structured description of neoplasm focality, type, location, nodules, and extent.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-tumor-observable-example"/>
      </entry>
    </section>
    <section>
      <title value="Tumour size (dimensions)"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Measured tumour dimensions including largest diameter and further axes.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-tumor-measurement-example"/>
      </entry>
    </section>
    <section>
      <title value="Oestrogen receptor (ER) status"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Immunohistochemical assessment of oestrogen receptor expression in tissue.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-estrogen-status"/>
      </entry>
    </section>
    <section>
      <title value="Progesterone receptor (PR) status"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>Immunohistochemical assessment of progesterone receptor expression in tissue.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-progesterone-status"/>
      </entry>
    </section>
    <section>
      <title value="HER2 receptor status"/>
      <text>
        <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p>HER2 testing result (e.g. IHC/FISH interpretation) for treatment planning.</p></div>
      </text>
      <entry>
        <reference value="Observation/observation-her2-receptor-status-example"/>
      </entry>
    </section>
  </section>
  <section>
    <title value="Synthesis (Conclusion/Integrated Diagnosis)"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="22637-3"/>
        <display value="Pathology report final diagnosis Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><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>
    </text>
    <section>
      <title value="Diagnostic report (signed)"/>
      <text>
        <status value="generated"/><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>
      </text>
      <entry>
        <reference value="DiagnosticReport/diagnosticreport-pathology-report-example"/>
      </entry>
    </section>
    <section>
      <title value="Example: prostate cancer stage (Condition)"/>
      <text>
        <status value="generated"/><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>
      </text>
      <entry>
        <reference value="Condition/condition-prostate-cancer-example"/>
      </entry>
    </section>
  </section>
</Composition>