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
<Composition xmlns="http://hl7.org/fhir">
<id value="composition-pathology-example"/>
<meta>
<profile
value="https://hl7.lt/fhir/lab/StructureDefinition/pathology-composition-lt-lab"/>
</meta>
<language value="lt"/>
<text>
<status value="generated"/>
<div xml:lang="lt" lang="lt"><hr/><p><b>Lithuanian</b></p><hr/><p class="res-header-id"><b>Generated Narrative: Composition composition-pathology-example</b></p><a name="lt-composition-pathology-example"> </a><a name="lt-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>
</text>
<identifier>
<system value="http://hospital.lt/sid/composition-number"/>
<value value="4540-baab-7a5d0877428f-93468-45y72547"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://snomed.info/sct"/>
<code value="371528001"/>
<display value="Pathology report (record artifact)"/>
</coding>
</type>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="26436-6"/>
<display value="Laboratory Studies (set)"/>
</coding>
</category>
<subject>🔗
<reference value="Patient/patient-example"/>
</subject>
<date value="2022-10-25T14:30:00+01:00"/>
<author>🔗
<reference value="Practitioner/practitioner-example"/>
</author>
<title value="Histological examination of the breast tissue"/>
<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>