Repositorio de Reportes de Biopsias Oncológicas
0.1.1-draft - STU1
Repositorio de Reportes de Biopsias Oncológicas
0.1.1-draft - STU1
Repositorio de Reportes de Biopsias Oncológicas, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/R2BO/ and changes regularly. See the Directory of published versions
Document Details
Profile: Perfil de Bundle del Documento
Final Document at 2021-08-01 10:00:00-0400 by PractitionerRole MÉDICO CIRUJANO for Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
Document Subject
Profile: MINSAL Paciente
Javiera Castilla (official) Female, DoB: 1995-12-12 ( RUN: 16182522-0 (use: official, ))
| Active: | true | Deceased: | false |
| Marital Status: | Soltero(a) | ||
| Other Id: | PPN/ACL123456789876 (use: official, ) | ||
| Contact Detail |
| ||
| Sexo Biologico del paciente | Femenina | ||
| País de origen del paciente | Uruguay | ||
| Pueblos Originarios: |
| ||
| Código de Países | Chile | ||
| Religión | Ninguna, ateo, agnóstico | ||
| Identidad De Género | Femenina | ||
| Pueblos Afrodescendiente | false | ||
Document Content
Notas del Informe de Biopsia:
Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral
Entry 2 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/ServiceRequest/r2bo-solicitud-informe-apa-ej
Resource ServiceRequest:
version: 2
Profile: Perfil de Solicitud de Informe de Anatomía Patológica
identifier: 111111101
status: Completed
intent: Order
priority: Routine
code: No display for ServiceRequest.code (concept: Pathologist report)
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
requester: PractitionerRole MÉDICO CIRUJANO
performer: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco)
Entry 3 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Patient/paciente-requiere-examen
Resource Patient:
Profile: MINSAL Paciente
Javiera Castilla (official) Female, DoB: 1995-12-12 ( RUN: 16182522-0 (use: official, ))
Active: true Deceased: false Marital Status: Soltero(a) Other Id: PPN/ACL123456789876 (use: official, ) Contact Detail
- +56912387678
- Avenida Las Torres 3456, Departamento 702 null null null (home)
Sexo Biologico del paciente Femenina País de origen del paciente Uruguay Pueblos Originarios:
- pertenece: false
Código de Países Chile Religión Ninguna, ateo, agnóstico Identidad De Género Femenina Pueblos Afrodescendiente false
Entry 4 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/PractitionerRole/ProfesionalHospital
Resource PractitionerRole:
Profile: Perfil de Rol Profesional
practitioner: Practitioner Juan Perez
organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco)
code: MÉDICO CIRUJANO
location: Location Medicina General
Entry 5 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/PractitionerRole/r2bo-anatopatologo-hospital
Resource PractitionerRole:
Profile: Perfil de Rol Profesional
practitioner: Practitioner Patricia Gutierrez
organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco)
code: MÉDICO CIRUJANO
specialty: ANATOMÍA PATOLÓGICA
Entry 6 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Practitioner/profesional-hospital-collector
Resource Practitioner:
Profile: Prestador Profesional
identifier: RUN/5135329-3 (use: official, )
name: Juan Perez
birthDate: 1991-05-18
Qualifications
Identifier Code cert MÉDICO CIRUJANO
Entry 7 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Practitioner/profesional-hospital-anatopatologo
Resource Practitioner:
Profile: Prestador Profesional
identifier: RUN/19283789-2 (use: official, )
name: Patricia Gutierrez
gender: Female
birthDate: 1983-11-18
qualification
identifier: cert
code: MÉDICO CIRUJANO
qualification
identifier: esp
code: MEDICINA INTERNA
qualification
identifier: subesp
code: ANATOMÍA PATOLÓGICA
Entry 8 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Organization/hospital-collector
Resource Organization:
Profile: Prestador Institucional
identifier: 121109
name: Hospital Dr. Hernán Henríquez Aravena (Temuco)
Entry 9 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Specimen/r2bo-specimen-example
Resource Specimen:
Profile: Perfil de Muestra
identifier: 110101101
status: Available
type: Tissue
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
receivedTime: 2021-06-01 00:00:00+0000
Collections
Collector Collected[x] Method BodySite PractitionerRole MÉDICO CIRUJANO 2021-06-01 10:00:00+0000 Biopsy of breast No display for Specimen.collection.bodySite (concept: Structure of breast) note:
Resección completa de tejido mamario, posible carcinoma
Entry 10 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-microscopica-ex
Resource Observation:
Profile: Perfil de Observación Microscópica
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Pathology report microscopic observation in Specimen
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos
Entry 11 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/BodyStructure/r2bo-tumor-ex
Resource BodyStructure:
morphology: Carcinoma ductal infiltrante
patient: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
Entry 12 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-macroscopica-ex
Resource Observation:
Profile: Perfil de Observación Macroscópica
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Macroscopic observation [Interpretation] in Specimen Narrative
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista
Entry 13 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-estadificacion-tnm-ex
Resource Observation:
Profile: Perfil de Grupo Estadificación TNM
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Pathologic TNM stage grouping
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
hasMember:
Entry 14 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-tumor-primario-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: pT category
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: pT2 (AJCC)
Entry 15 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-nodo-regional-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: pN category
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: pN2 (AJCC)
Entry 16 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-metastasis-distantel-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: pM category
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: pM1 (AJCC)
Entry 17 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-infiltracion-perineural-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Presence of direct invasion by primary malignant neoplasm to nerve
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Perineural invasion by tumour not identified
Entry 18 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-ganglios-linfaticos-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Lymph nodes with metastasis [#] in Cancer specimen
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: true
Components
Code Value[x] Number 4
Entry 19 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-infiltracion-peritumoral-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Status of peritumoral lymphocyte response
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Marked peritumoral lymphocytic response
Entry 20 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-invasion-linfatica-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Present
Entry 21 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-invasion-vascular-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: Present
Entry 22 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-margen-quirurgico-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Surgical margin observable
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
component
code: Surgical margin site involved by tumour
value: Positive
component
code: Distance of tumor from closest margin
value: 1.5 Millimeter (Details: UCUM codemm = 'millimeter')
Entry 23 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-centricidad-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Multiple tumors reported as single primary Cancer
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: true
Components
Code Value[x] Number 2
Entry 24 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-multifocalidad-ex
Resource Observation:
Profile: Perfil de Observación Focalidad
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Status of specimen involvement by multifocal invasion
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: true
Components
Code Value[x] Number 2
Entry 25 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-porcentaje-necrosis-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Percentage of tumour involved by necrosis
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: 5 % (Details: UCUM code% = 'percent')
Entry 26 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-post-tratamiento-neoadjuvancia-ex
Resource Observation:
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Tumor response to neoadjuvant therapy
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
value: El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.
Entry 27 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tamano-tumor-ex
Resource Observation:
Profile: Perfil de Tamaño del Tumor
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Size Tumor
subject: Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
effective: 2021-06-01 12:00:00-0400
performer: PractitionerRole MÉDICO CIRUJANO
component
code: Size.maximum dimension in Tumor
value: 1.5 cm (Details: UCUM codecm = 'centimeter')
component
code: Size additional dimension in Tumor
value: 1.2 cm (Details: UCUM codecm = 'centimeter')
component
code: Size additional dimension in Tumor
value: 0.7 cm (Details: UCUM codecm = 'centimeter')