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

## : Informe de Anatomía Patológica de Biopsia de Mama - XML Representation

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    <DiagnosticReport xmlns="http://hl7.org/fhir">
      <id value="r2bo-informe-biopsia-ex"/>
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        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: DiagnosticReport 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}">Macroscopic observation [Interpretation] in Specimen Narrative</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}">Lymph nodes with metastasis [#] in Cancer specimen</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}">Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols</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}">Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols</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}">Multiple tumors reported as single primary Cancer</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}">Tumor response to neoadjuvant therapy</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}">Size Tumor</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>
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                  value="Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral"/>
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