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 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/riap/ and changes regularly. See the Directory of published versions

Example DiagnosticReport: Informe de Anatomía Patológica de Biopsia de Mama

Page standards status: Informative

Informe de Biopsia de Mama (Pathology (gross & histopath, not surgical))

SubjectJaviera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, ))
Reported2021-08-01 10:00:00-0400
Performer PractitionerRole MÉDICO CIRUJANO
Identifier r2bo-2020-0001

Report Details

CodeValueFlagsWhen For
Pathology report microscopic observation in SpecimenSe observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticosFinal2021-06-01 12:00:00-0400
Macroscopic observation [Interpretation] in Specimen NarrativeMuestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vistaFinal2021-06-01 12:00:00-0400
399588009Final2021-06-01 12:00:00-0400
Lymph nodes with metastasis [#] in Cancer specimentrueFinal2021-06-01 12:00:00-0400
371513001385001000Final2021-06-01 12:00:00-0400
371509008369762001Final2021-06-01 12:00:00-0400
Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols52101004Final2021-06-01 12:00:00-0400
Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols52101004Final2021-06-01 12:00:00-0400
396631001Final2021-06-01 12:00:00-0400
Multiple tumors reported as single primary CancertrueFinal2021-06-01 12:00:00-0400
444696007trueFinal2021-06-01 12:00:00-0400
4059210025 % (Details: UCUM code% = '%')Final2021-06-01 12:00:00-0400
Tumor response to neoadjuvant therapyEl tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.Final2021-06-01 12:00:00-0400
Size TumorFinal2021-06-01 12:00:00-0400

Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral

Coded Conclusions:

  • Carcinoma ductal infiltrante
  • Mama