Ejemplo del Documento un Informe de Anatomía Patológica - Repositorio de Reportes de Biopsias Oncológicas v0.1.1-draft

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

Example Bundle: Ejemplo del Documento un Informe de Anatomía Patológica

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

+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

Document Content

Solicitud de Biopsia

Muestra de Biopsia

Macroscopia de Biopsia

Microscopia de Biopsia

Hallazgos de Biopsia

Conclusiones de Biopsia

Notas del Informe de Biopsia

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

Additional Resources Included in Document

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Rec}:

version: 2
Profile: Perfil de Solicitud de Informe de Anatomía Patológica
identifier: 111111101
status: Completed
intent: Order
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)
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

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Rec}:

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

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Rec}:

Profile: Perfil de Rol Profesional
practitioner: Practitioner Juan Perez
organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco)
code: MÉDICO CIRUJANO

Entry 5 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/PractitionerRole/r2bo-anatopatologo-hospital

Rec}:

Profile: Perfil de Rol Profesional
practitioner: Practitioner Patricia Gutierrez
organization: Organization Hospital Dr. Hernán Henríquez Aravena (Temuco)
code: MÉDICO CIRUJANO
specialty: ANATOMÍA PATOLÓGICA

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Rec}:

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

Rec}:

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

Rec}:

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

Rec}:

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

Rec}:

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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 11 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/BodyStructure/r2bo-tumor-ex

Rec}:

Profile: Peril de la Morfología y Topología del Tumor
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

Rec}:

Profile: Perfil de Observación Macroscópica
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Observación macroscópica: XXX : Punto temporal: Impresión / interpretación del estudio: Narrativo:
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 13 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-estadificacion-tnm-ex

Rec}:

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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
hasMember:
Observation pT category
Observation pN category
Observation pM category

Entry 14 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-tumor-primario-ex

Rec}:

Profile: Perfil de Categoria TNM Tumor Primario
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)
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 15 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-nodo-regional-ex

Rec}:

Profile: Perfil de Categoria TNM Nodos Regional
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)
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 16 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tnm-categoria-metastasis-distantel-ex

Rec}:

Profile: Perfil de Categoria TNM de Metástasis Distante
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)
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 17 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-infiltracion-perineural-ex

Rec}:

Profile: Perfil de Observación Infiltración Perineural
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 18 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-ganglios-linfaticos-ex

Rec}:

Profile: Perfil de Observación Ganglios Linfáticos
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Ganglios linfáticos con metástasis: Espécimen de cáncer : Punto temporal: Número (recuento): Cuantitativo:
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Components
- Code Value[x]
* Number 4

Entry 19 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-infiltracion-peritumoral-ex

Rec}:

Profile: Perfil de Observación Infiltración Peritumoral
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 20 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-invasion-linfatica-ex

Rec}:

Profile: Perfil de Observación Invasión Linfatica
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Invasión linfática de vasos subs: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 21 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-invasion-vascular-ex

Rec}:

Profile: Perfil de Observación Invasión Vascular
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Invasión de vasos grandes venosos: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 22 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-margen-quirurgico-ex

Rec}:

Profile: Perfil de Observación Margen Quirúrgico
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
component
code: Surgical margin site involved by tumour
value: Positive
component
code: Distancia del tumor al margen más cercano: Muestra : Punto temporal: Largo: Cuantitativo:
value: 1.5 Millimeter (Details: UCUM codemm = 'millimeter')

Entry 23 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-centricidad-ex

Rec}:

Profile: Perfil de Observación Multicentricidad
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Múltiples tumores informados como primarios únicos:Cancer.XXX :Punto temporal:Tipo:Nominal:
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Components
- Code Value[x]
* Number 2

Entry 24 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-multifocalidad-ex

Rec}:

Profile: Perfil de Observación Multifocalidad
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
Components
- Code Value[x]
* Number 2

Entry 25 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-porcentaje-necrosis-ex

Rec}:

Profile: Perfil de Observación Porcentaje Necrosis
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')
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 26 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-observacion-post-tratamiento-neoadjuvancia-ex

Rec}:

Profile: Perfil de Observación Evaluación Post Neoadyuvancia
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Respuesta a la terapia neoadyuvante: Muestra de cáncer colorrectal : Punto temporal: Presencia o umbral: Ordinal:
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.
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma

Entry 27 - fullUrl = https://interoperabilidad.minsal.cl/fhir/ig/r2bo/Observation/r2bo-tamano-tumor-ex

Rec}:

Profile: Perfil de Tamaño del Tumor
basedOn: ServiceRequest Pathologist report
status: Final
category: Laboratory
code: Tamaño:Tumor :Punto temporal:Len:Cuantitativo:
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
specimen: Specimen: identifier = 110101101; status = available; type = Tissue; receivedTime = 2021-06-01 00:00:00+0000; note = Resección completa de tejido mamario, posible carcinoma
component
code: Size.max.dimension: Tumor : Punto temporal: Largo: Cuantitativo:
value: 1.5 cm (Details: UCUM codecm = 'centimeter')
component
code: Tamaño dimensión adicional: Tumor : Punto temporal: Largo: Cuantitativo:
value: 1.2 cm (Details: UCUM codecm = 'centimeter')
component
code: Tamaño dimensión adicional: Tumor : Punto temporal: Largo: Cuantitativo:
value: 0.7 cm (Details: UCUM codecm = 'centimeter')