Repositorio de Reportes de Biopsias Oncológicas
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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

: Informe de Anatomía Patológica de Biopsia de Mama - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:DiagnosticReport ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "r2bo-informe-biopsia-ex"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia"^^xsd:anyURI ;
fhir:link <https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InformeDiagnostico r2bo-informe-biopsia-ex</b></p><a name=\"r2bo-informe-biopsia-ex\"> </a><a name=\"hcr2bo-informe-biopsia-ex\"> </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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-r2bo-informe-biopsia.html\">Perfil del Reporte de Anatomía Patológica</a></p></div><h2><span title=\"Codes:{http://loinc.org 66110-8}\">Informe de Biopsia de Mama</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 PAT}\">Pathology (gross &amp; histopath, not surgical)</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))</td></tr><tr><td>Reported</td><td>2021-08-01 10:00:00-0400</td></tr><tr><td>Performer</td><td> <a href=\"PractitionerRole-r2bo-anatopatologo-hospital.html\">PractitionerRole MÉDICO CIRUJANO</a></td></tr><tr><td>Identifier</td><td> r2bo-2020-0001</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href=\"Observation-r2bo-observacion-microscopica-ex.html\"><span title=\"Codes:{http://loinc.org 102034-6}\">Pathology report microscopic observation in Specimen</span></a></td><td>Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-macroscopica-ex.html\"><span title=\"Codes:{http://loinc.org 74574-5}\">Observación macroscópica: XXX : Punto temporal: Impresión / interpretación del estudio: Narrativo:</span></a></td><td>Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-estadificacion-tnm-ex.html\"><span title=\"Codes:{http://snomed.info/sct 399588009}\">Pathologic TNM stage grouping</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-ganglios-linfaticos-ex.html\"><span title=\"Codes:{http://loinc.org 92831-7}\">Ganglios linfáticos con metástasis: Espécimen de cáncer : Punto temporal: Número (recuento): Cuantitativo:</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-infiltracion-perineural-ex.html\"><span title=\"Codes:{http://snomed.info/sct 371513001}\">Presence of direct invasion by primary malignant neoplasm to nerve</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 385001000}\">Perineural invasion by tumour not identified</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-infiltracion-peritumoral-ex.html\"><span title=\"Codes:{http://snomed.info/sct 371509008}\">Status of peritumoral lymphocyte response</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 369762001}\">Marked peritumoral lymphocytic response</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-invasion-linfatica-ex.html\"><span title=\"Codes:{http://loinc.org 33739-4}\">Invasión linfática de vasos subs: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 52101004}\">Present</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-invasion-vascular-ex.html\"><span title=\"Codes:{http://loinc.org 33740-2}\">Invasión de vasos grandes venosos: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 52101004}\">Present</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-margen-quirurgico-ex.html\"><span title=\"Codes:{http://snomed.info/sct 396631001}\">Surgical margin observable</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-centricidad-ex.html\"><span title=\"Codes:{http://loinc.org 42030-7}\">Múltiples tumores informados como primarios únicos:Cancer.XXX :Punto temporal:Tipo:Nominal:</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-multifocalidad-ex.html\"><span title=\"Codes:{http://snomed.info/sct 444696007}\">Status of specimen involvement by multifocal invasion</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-porcentaje-necrosis-ex.html\"><span title=\"Codes:{http://snomed.info/sct 405921002}\">Percentage of tumour involved by necrosis</span></a></td><td>5 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = 'percent')</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-post-tratamiento-neoadjuvancia-ex.html\"><span title=\"Codes:{http://loinc.org 84891-1}\">Respuesta a la terapia neoadyuvante: Muestra de cáncer colorrectal : Punto temporal: Presencia o umbral: Ordinal:</span></a></td><td>El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-tamano-tumor-ex.html\"><span title=\"Codes:{http://loinc.org 21889-1}\">Tamaño:Tumor :Punto temporal:Len:Cuantitativo:</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr></table><p>Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral</p><p><b>Coded Conclusions:</b></p><ul><li><span title=\"Codes:{http://snomed.info/sct 82711006}, {http://terminology.hl7.org/CodeSystem/icd-o-3 8500/3}\">Carcinoma ductal infiltrante</span></li><li><span title=\"Codes:{http://snomed.info/sct 76752008}, {http://terminology.hl7.org/CodeSystem/icd-o-3 C50.9}\">Mama</span></li></ul></div>"^^rdf:XMLLiteral
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Composition/r2bo-documento-biopsia-ex" ]     ]
  ] ) ; # 
  fhir:identifier ( [
fhir:value [ fhir:v "r2bo-2020-0001" ]
  ] ) ; # 
  fhir:basedOn ( [
fhir:reference [ fhir:v "ServiceRequest/r2bo-solicitud-informe-apa-ej" ]
  ] ) ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:category ( [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0074"^^xsd:anyURI ] ;
fhir:code [ fhir:v "PAT" ] ;
fhir:display [ fhir:v "Pathology (gross & histopath, not surgical)" ]     ] )
  ] ) ; # 
  fhir:code [
    ( fhir:coding [
a loinc:66110-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "66110-8" ]     ] ) ;
fhir:text [ fhir:v "Informe de Biopsia de Mama" ]
  ] ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/paciente-requiere-examen" ]
  ] ; # 
  fhir:issued [ fhir:v "2021-08-01T10:00:00-04:00"^^xsd:dateTime] ; # 
  fhir:performer ( [
fhir:reference [ fhir:v "PractitionerRole/r2bo-anatopatologo-hospital" ]
  ] ) ; # 
  fhir:specimen ( [
fhir:reference [ fhir:v "Specimen/r2bo-specimen-example" ]
  ] ) ; # 
  fhir:result ( [
fhir:reference [ fhir:v "Observation/r2bo-observacion-microscopica-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-macroscopica-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-estadificacion-tnm-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-ganglios-linfaticos-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-infiltracion-perineural-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-infiltracion-peritumoral-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-invasion-linfatica-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-invasion-vascular-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-margen-quirurgico-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-centricidad-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-multifocalidad-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-porcentaje-necrosis-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-observacion-post-tratamiento-neoadjuvancia-ex" ]
  ] [
fhir:reference [ fhir:v "Observation/r2bo-tamano-tumor-ex" ]
  ] ) ; # 
  fhir:conclusion [ fhir:v "Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral"] ; # 
  fhir:conclusionCode ( [
fhir:id [ fhir:v "Morfologico" ] ;
    ( fhir:coding [
a sct:82711006 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "82711006" ]     ] [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/icd-o-3"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8500/3" ]     ] ) ;
fhir:text [ fhir:v "Carcinoma ductal infiltrante" ]
  ] [
fhir:id [ fhir:v "Topografico" ] ;
    ( fhir:coding [
a sct:76752008 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "76752008" ]     ] [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/icd-o-3"^^xsd:anyURI ] ;
fhir:code [ fhir:v "C50.9" ]     ] ) ;
fhir:text [ fhir:v "Mama" ]
  ] ) . #