MyHealtheVet PHR FHIR API
0.3.9-current - ci-build
MyHealtheVet PHR FHIR API, published by VA Digital Services. This guide is not an authorized publication; it is the continuous build for version 0.3.9-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/department-of-veterans-affairs/mhv-fhir-phr-mapping/ and changes regularly. See the Directory of published versions
Page standards status: Informative |
This is a sample of a note that was signed, and for which an addenda is being added. Given that the addenda is not signed, the text body indicates that there is an addenda that is not accessible. This addenda is signed in note-6.
Derived from the following mock NoteTO:
<noteTO>
<id>5298388</id>
<timestamp>3231116.144</timestamp>
<localTitle>STAGING (TNM) URINARY BLADDER</localTitle>
<author>
<id>36556</id>
<name>AHMED,MARUF</name>
</author>
<location>
<id>984ZZI</id>
<name>ZZDAYTSHR</name>
</location>
<text>LOCAL TITLE: STAGING (TNM) URINARY BLADDER
DATE OF NOTE: NOV 16, 2023@14:40 ENTRY DATE: NOV 16, 2023@14:40:47
AUTHOR: AHMED,MARUF EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** STAGING (TNM) URINARY BLADDER Has ADDENDA ***
URINARY BLADDER
6th edition AJCC Cancer Staging Manual
testing note with kbst team
CLIN PATH PRIMARY TUMOR (T)
[X] [ ] TX Primary tumor cannot be assessed
[ ] [ ] T0 No evidence of primary tumor
[ ] [ ] Ta Non invasive papillary carcinoma
[ ] [ ] Tis Carcinoma in situ (flat tumor)
[X] [ ] T1 Tumor invades subepithelial connective tissue
[ ] [ ] T2 Tumor invades muscle
[ ] [ ] T2a Tumor Invades superficial (inner half)
[ ] [ ] T2b Tumor Invades deep muscle (outer half)
[ ] [X] T3 Tumor invades perivesical tissue
[ ] [X] T3a Microscopically
[ ] [ ] T3b Macroscopically (extravesical mass)
[ ] [ ] T4 Tumor invades any of the following: prostate,
uterus, vagina, pelvic or abdominal wall
[ ] [ ] T4a Tumor invades prostate, uterus, vagina
[X] [X] T4b Tumor invades pelvic wall, abdominal wall
REGIONAL LYMPH NODES (N)
[ ] [ ] NX Regional lymph node metastasis cannot be assessed
[ ] [ ] N0 No regional lymph node metastasis
[ ] [X] N1 Mets in a single lymph node, 2 cm or less in
greatest dimension.
[ ] [X] N2 Mets in a single lymph node more than 2 but not
more than 5 cm in greatest dimension; multiple
lymph nodes, none more than 5 cm in greatest
dimension.
[ ] [ ] N3 Metastasis in a lymph node more than 5 cm
DISTANT METASTASIS (M)
[ ] [X] MX Presence of distant metastasis cannot be assessed
[ ] [X] M0 No distant metastasis
[ ] [ ] M1 Distant metastasis
STAGE GROUPING
[ ] [ ] Oa Ta N0 M0
[ ] [ ] Ois Tis N0 M0
[ ] [ ] I T1 N0 M0
[ ] [X] II T2a N0 M0
[ ] [ ] T2b N0 M0
[ ] [ ] III T3a N0 M0
[ ] [X] T3b N0 M0
[ ] [ ] T4a N0 M0
[ ] [ ] IV T4b N0 M0
[X] [ ] Any T N1 M0
[X] [ ] Any T N2 M0
[X] [ ] Any T N3 M0
[X] [ ] Any T Any N M1
GRADE
[ ] GX Grade cannot be assessed
[X] G1 Well differentiated
[X] G2 Mod differentiated
[ ] G3 Poorly differentiated
[ ] G4 Undifferentiated
OP #598c (552) Approved 12/99 Rev 03/03
/es/ MARUF AHMED
PHYSICIAN
Signed: 11/16/2023 14:50
11/16/2023 ADDENDUM STATUS: UNSIGNED
You may not VIEW this UNSIGNED Addendum.</text>
<approvedBy>
<id>36556</id>
<name>AHMED,MARUF</name>
<signature>MARUF AHMED PHYSICIAN</signature>
</approvedBy>
<status>completed</status>
<type>PN</type>
<procTimestamp>3231116.145026</procTimestamp>
</noteTO>
Generated Narrative: DocumentReference ex-MHV-note-5
identifier: urn:oid:2.16.840.1.113883.4.349.4.989
/NoteTO.5298388 (use: usual, )
status: Current
type: Progress note
category: Clinical Note
subject: MTPZEROTWO DAYTSHR Male, DoB: 1000-01-01 ( urn:oid:2.16.840.1.113883.4.349#1 (use: usual, ))
date: 2023-11-16 14:40:00+0000
author: Practitioner AHMED,MARUF
authenticator: Practitioner AHMED,MARUF
content
Attachments
ContentType Data Title text/plain (base64 data - 4,160 base64 chars) STAGING (TNM) URINARY BLADDER
Related |
Location DAYTSHR TEST LAB |
Generated Narrative: Practitioner #ex-MHV-practitioner-36556
identifier:
urn:oid:2.16.840.1.113883.4.349.4.989
/AuthorTO.37556 (use: usual, )name: AHMED,MARUF
Generated Narrative: Location #ex-MHV-location-984
identifier:
urn:oid:2.16.840.1.113883.4.349.4.989
/HospitalLocationTO.984 (use: usual, )name: DAYTSHR TEST LAB