Connectathon 11 Snapshot
This page is part of the FHIR Specification (v1.2.0: STU 3 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
Colorectal cancer.
Structure
| Name | Flags | Card. | Type | Description & Constraints | Implemented As |
|---|---|---|---|---|---|
  Colorectal | Logical | Colorectal | dr := DiagnosticReport | ||
  subject | Σ | 1..1 | Reference(Patient | Group) | The subject of the report, usually, but not always, the patient | dr.subject |
| requester | Σ | 0..1 | Reference(Practitioner) | Who ordered the test | !req := dr.request→DiagnosticOrder; req[orderer := $value] |
| performer | Σ | 0..1 | Reference(Practitioner | Organization) | Responsible Diagnostic Service | dr[performer := $value] |
 preAnalytic | I | 0..1 | Element | Pre Analytic If there is a perforation, the perforation type must be indicated. | req := dr.request→DiagnosticOrder; req[orderer := $value] |
  clinicalInformation | 0..1 | string | Clinical information | req.reason[text := $value] | |
| operatingSurgeonDetails | Σ | 0..1 | Reference(Practitioner) | Operating surgeon details | sp := dr.specimen→Specimen; sp.collection[collector := $value] |
| perforation | I | 0..1 | code | Perforation PresentAbsentNotstated (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| natureOfPerforation | 0..* | code | Nature of perforation NehtaNatureOfPerforation (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| clinicalObstruction | 0..1 | code | Clinical obstruction PresentAbsentNotstated (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| tumourLocation | I | 0..* | code | Tumour location ColorectalCancerTumourLocation (Required) If the tumour location is rectum, then the distance from the anal verge must be recorded. | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| synchronousTumours | 0..1 | string | Synchronous tumours - other site | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
 distanceAnalVerge | 0..1 | SimpleQuantity | Distance from anal verge | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| typeOfOperation | I | 0..1 | code | * ColorectalCancerOperationType (Required) If other procedure(s) is selected, then record the type of procedure. If anterior resection is selected, record anterior resection type. | too := req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| typeOfProcedure | 0..1 | string | Procedure type | too.text | |
| anteriorResectionType | 0..1 | code | Anterior resection type HiLowUltralow (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| preoperativeRadiotherapy | I | 0..1 | code | Pre-operative radiotherapy YesNoNotStated (Required) If pre-operative radiotherapy is done, then the type of course is to be recorded. | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| typeOfCourse | 0..1 | code | Type of course TypeOfCourse (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| surgeonsOpinion | 0..1 | string | Surgeons opinion of residual cancer | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| adjacentOrgans | 0..1 | string | Adjacent organ involvement | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| newPrimaryOrRecurrence | I | 0..1 | code | New primary cancer or recurrence NehtaCancerPrimaryOrRecurrence (Required) If regional (local) recurrence or distant metastasis describe. | pno := req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| RecurrenceDescription | 0..1 | string | Describe | pno.component[code := %map-codes; value[x] := $value] | |
| pathologyAccessionNumber | 0..1 | string | Pathology number | dr[identifier := $value] | |
 otherRelevantDetails | 0..1 | string | Other details | req.note[text := $value] | |
| macro | I | 0..1 | Element | Macroscopy If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded. If lymph nodes are received, record the number of nodes | macro := dr.result→Observation[code := %map-codes] |
| specimenLength | 1..1 | SimpleQuantity | Specimen length | sp1 := dr.specimen→Specimen; sp1.collection[quantity := $value] | |
| tumourSite | I | 1..1 | code | Tumour site ColorectalCancerTumourLocation (Required) If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded. If tumour site is rectum, the intactness of mesorectum is to be recorded. If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded. | sp2 := dr.specimen→Specimen; sp2.collection[bodySite := $value] |
| maxTumourDiameter | 1..1 | SimpleQuantity | Max. tumour diameter | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| distanceNearerProxOrDistal | 1..* | SimpleQuantity | Dist. of tumour to the nearer proximal or distal "cut end" | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| distNonperitonCircumMargin | 1..1 | SimpleQuantity | Dist. of tumour to the nonperitonealised circumferential margin | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourPerforation | 1..1 | code | Tumour perforation PresentAbsent (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| relToAntPeritonealReflection | 0..1 | code | Relationship to anterior peritoneal reflection NehtaRelAnteriorPeritonealReflection (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| intactnessOfMesorectum | 0..1 | code | Intactness of mesorectum MesorectumIntactness (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| peritoneum | 0..1 | code | Peritoneum NehtaPeritoneumInvasion (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| lymphNodes | I | 0..1 | code | Lymph nodes ReceivedNotreceived (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| noLymphNodesPerCassette | 0..* | string | Number of lymph nodes in each cassette | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| polyps | I | 0..1 | code | Polyps PresentAbsent (Required) If polyps are present, provide a polyp summary. | macro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| polypSummary | 0..1 | string | The number, diameter and gross configuration of polyps should be summarised | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| otherMacroComments | 0..1 | string | Other macroscopic comments | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| natureAndSiteOfBlocks | 1..* | string | Nature and site of blocks | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| micro | 0..1 | Element | Microscopy | micro := dr.result→Observation[code := %map-codes] | |
| tumourType | 1..1 | code | Tumour type TumourType (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| histologicalGrade | 1..1 | code | Histological grade HistologicalGrade (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| maxDegreeLocalInvasion | 1..1 | code | Maximum degree of local invasion into or through the bowel wall DegreeInvasionBowelWall (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| proximalOrDistalResectionMargins | I | 0..1 | code | Involvement of the proximal or distal resection (cut-end) margins CRCInvolvedNotinvolved (Required) If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance. If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s). | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| involvedMargins | 1..* | code | Involved margin(s) DistalProximal (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| marginsMicroClearance | 0..1 | SimpleQuantity | Microscopic Clearance | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| nonperitonealisedCircumMargin | I | 0..1 | code | Status of the nonperitonealised circumferential margin (rectal tumours) InvolvedNotinvolved (Required) If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| microClearanceRectum | 0..1 | SimpleQuantity | Microscopic Clearance | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| lymphNodeInvolvement | I | 0..1 | code | Lymph node involvement PresentAbsent (Required) If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| lymphNodesDetails | 0..* | string | Site(s) and numbers of lymph nodes | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| extramuralTumourDeposits | 0..1 | code | Isolated extra-mural tumour deposits PresentAbsent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| apicalNodeInvolvement | 0..1 | code | Apical node involvement PresentAbsent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| venousSmallVesselInvasion | 0..1 | string | Venous and small vessel invasion | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| intramuralVeinInvasion | 1..1 | code | Intramural vein invasion NotIdentifiedPresent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| extramuralVeinInvasion | 1..1 | code | Extramural vein invasion NotIdentifiedPresent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| smallVesselInvasion | 1..1 | code | Small vessel invasion NotIdentifiedPresentPresentExtensive (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| perineuralInvasion | 1..1 | code | Perineural invasion NotIdentifiedPresentPresentExtensive (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| histoConfDistMetastases | I | 1..1 | code | Histologically confirmed distant metastases PresentAbsent (Required) If histologically confirmed distant metastases are present then the sites are to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| histoConfDistMetastasesSite | 0..1 | string | Histologically confirmed distant metastases - site | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| relCoexistPathabnorm | I | 1..* | code | Relevant coexistent pathological abnormalities CoexistentPathologicalAbnormalities (Required) If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded. If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| polypDetails | 0..1 | string | Polyp details (type, number, polyposis syndrome criteria met etc) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| dysplasia | 0..1 | code | Dysplasia Dysplasia (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| otherAbnormality | 0..1 | string | Other abnormality | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| microResidualTumourStatus | 1..1 | string | Microscopic residual tumour status (completeness of resection) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| neoadjuvantTherapy | 0..1 | code | Response to neoadjuvant therapy ResponseToNeoadjuvantTherapy (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| microComments | 0..1 | string | Microscopic comments | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| ancillaryTests | 0..1 | Element | Ancillary test findings | ancillary := dr.result→Observation[code := %map-codes] | |
 mismatchRepairEnz | 1..1 | Mismatch repair enzymes | |||
| mlh1 | 0..1 | code | MLH-1 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| pms2 | 0..1 | code | PMS-2 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msh2 | 0..1 | code | MSH-2 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msh6 | 0..1 | code | MSH-6 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| comments | 0..1 | string | Mismatch repair enzyme comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msi | I | 0..1 | Element | Microsatellite instability (MSI) | |
| code | I | 0..1 | code | Microsatellite instability (MSI) UnstableStable (Required) If MSI unstable, record laboratory performing test and report number If MSI stable, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | Microsatellite instability (MSI) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | MSI laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| braf | I | 0..1 | Element | BRAF (V600E mutation) | |
| code | I | 0..1 | code | BRAF (V600E mutation) MutatedWildtype (Required) If BRAF mutated, record laboratory performing test and report number If BRAF wild type, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | BRAF (V600E mutation) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | BRAF (V600E mutation) laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| kras | I | 0..1 | Element | KRAS gene mutation (codons 12 and 13) | |
 code | I | 0..1 | code | KRAS gene mutation (codons 12 and 13) MutatedWildtype (Required) If KRAS wild type, record laboratory performing test and report number If KRAS mutated, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | KRAS gene mutation (codons 12 and 13) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | KRAS gene mutation (codons 12 and 13) laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| synthesisOverview | 0..1 | Element | Synthesis and Overview | synthesis := dr.result→Observation[code := %map-codes] | |
| tumourStage | 1..1 | string | Tumour stage | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageT | 0..1 | code | T CrcTumourStageT (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageN | 0..1 | code | N CrcTumourStageN (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageM | 0..1 | code | M CrcTumourStageM (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageGrouping | 1..1 | code | Stage grouping TumourStageGrouping (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStagingSystem | 1..1 | string | Year and/or edition of staging system | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| residualTumourStatus | 1..1 | string | Residual tumour status ResidualTumourStatus (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| diagnosticSummary | Σ | 0..1 | string | Diagnostic summary | dr[conclusion := $value] |
| newPrimaryOrRecurrence | 0..1 | code | New primary cancer or recurrence NewCancerOrRecurrence (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| newDescription | 0..1 | string | Describe | ||
| overarchingComment | 0..1 | string | Overarching comment | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| Documentation for this format | |||||
UML Diagram
Structure
| Name | Flags | Card. | Type | Description & Constraints | Implemented As |
|---|---|---|---|---|---|
| Colorectal | Logical | Colorectal | dr := DiagnosticReport | ||
| subject | Σ | 1..1 | Reference(Patient | Group) | The subject of the report, usually, but not always, the patient | dr.subject |
| requester | Σ | 0..1 | Reference(Practitioner) | Who ordered the test | !req := dr.request→DiagnosticOrder; req[orderer := $value] |
| performer | Σ | 0..1 | Reference(Practitioner | Organization) | Responsible Diagnostic Service | dr[performer := $value] |
| preAnalytic | I | 0..1 | Element | Pre Analytic If there is a perforation, the perforation type must be indicated. | req := dr.request→DiagnosticOrder; req[orderer := $value] |
| clinicalInformation | 0..1 | string | Clinical information | req.reason[text := $value] | |
| operatingSurgeonDetails | Σ | 0..1 | Reference(Practitioner) | Operating surgeon details | sp := dr.specimen→Specimen; sp.collection[collector := $value] |
| perforation | I | 0..1 | code | Perforation PresentAbsentNotstated (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| natureOfPerforation | 0..* | code | Nature of perforation NehtaNatureOfPerforation (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| clinicalObstruction | 0..1 | code | Clinical obstruction PresentAbsentNotstated (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| tumourLocation | I | 0..* | code | Tumour location ColorectalCancerTumourLocation (Required) If the tumour location is rectum, then the distance from the anal verge must be recorded. | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| synchronousTumours | 0..1 | string | Synchronous tumours - other site | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| distanceAnalVerge | 0..1 | SimpleQuantity | Distance from anal verge | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| typeOfOperation | I | 0..1 | code | * ColorectalCancerOperationType (Required) If other procedure(s) is selected, then record the type of procedure. If anterior resection is selected, record anterior resection type. | too := req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| typeOfProcedure | 0..1 | string | Procedure type | too.text | |
| anteriorResectionType | 0..1 | code | Anterior resection type HiLowUltralow (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| preoperativeRadiotherapy | I | 0..1 | code | Pre-operative radiotherapy YesNoNotStated (Required) If pre-operative radiotherapy is done, then the type of course is to be recorded. | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| typeOfCourse | 0..1 | code | Type of course TypeOfCourse (Required) | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| surgeonsOpinion | 0..1 | string | Surgeons opinion of residual cancer | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| adjacentOrgans | 0..1 | string | Adjacent organ involvement | req.supportingInformation → Observation[code := %map-codes; value[x] := $value] | |
| newPrimaryOrRecurrence | I | 0..1 | code | New primary cancer or recurrence NehtaCancerPrimaryOrRecurrence (Required) If regional (local) recurrence or distant metastasis describe. | pno := req.supportingInformation → Observation[code := %map-codes; value[x] := $value] |
| RecurrenceDescription | 0..1 | string | Describe | pno.component[code := %map-codes; value[x] := $value] | |
| pathologyAccessionNumber | 0..1 | string | Pathology number | dr[identifier := $value] | |
| otherRelevantDetails | 0..1 | string | Other details | req.note[text := $value] | |
| macro | I | 0..1 | Element | Macroscopy If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded. If lymph nodes are received, record the number of nodes | macro := dr.result→Observation[code := %map-codes] |
| specimenLength | 1..1 | SimpleQuantity | Specimen length | sp1 := dr.specimen→Specimen; sp1.collection[quantity := $value] | |
| tumourSite | I | 1..1 | code | Tumour site ColorectalCancerTumourLocation (Required) If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded. If tumour site is rectum, the intactness of mesorectum is to be recorded. If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded. | sp2 := dr.specimen→Specimen; sp2.collection[bodySite := $value] |
| maxTumourDiameter | 1..1 | SimpleQuantity | Max. tumour diameter | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| distanceNearerProxOrDistal | 1..* | SimpleQuantity | Dist. of tumour to the nearer proximal or distal "cut end" | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| distNonperitonCircumMargin | 1..1 | SimpleQuantity | Dist. of tumour to the nonperitonealised circumferential margin | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourPerforation | 1..1 | code | Tumour perforation PresentAbsent (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| relToAntPeritonealReflection | 0..1 | code | Relationship to anterior peritoneal reflection NehtaRelAnteriorPeritonealReflection (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| intactnessOfMesorectum | 0..1 | code | Intactness of mesorectum MesorectumIntactness (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| peritoneum | 0..1 | code | Peritoneum NehtaPeritoneumInvasion (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| lymphNodes | I | 0..1 | code | Lymph nodes ReceivedNotreceived (Required) | macro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| noLymphNodesPerCassette | 0..* | string | Number of lymph nodes in each cassette | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| polyps | I | 0..1 | code | Polyps PresentAbsent (Required) If polyps are present, provide a polyp summary. | macro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| polypSummary | 0..1 | string | The number, diameter and gross configuration of polyps should be summarised | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| otherMacroComments | 0..1 | string | Other macroscopic comments | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| natureAndSiteOfBlocks | 1..* | string | Nature and site of blocks | macro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| micro | 0..1 | Element | Microscopy | micro := dr.result→Observation[code := %map-codes] | |
| tumourType | 1..1 | code | Tumour type TumourType (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| histologicalGrade | 1..1 | code | Histological grade HistologicalGrade (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| maxDegreeLocalInvasion | 1..1 | code | Maximum degree of local invasion into or through the bowel wall DegreeInvasionBowelWall (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| proximalOrDistalResectionMargins | I | 0..1 | code | Involvement of the proximal or distal resection (cut-end) margins CRCInvolvedNotinvolved (Required) If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance. If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s). | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| involvedMargins | 1..* | code | Involved margin(s) DistalProximal (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| marginsMicroClearance | 0..1 | SimpleQuantity | Microscopic Clearance | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| nonperitonealisedCircumMargin | I | 0..1 | code | Status of the nonperitonealised circumferential margin (rectal tumours) InvolvedNotinvolved (Required) If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| microClearanceRectum | 0..1 | SimpleQuantity | Microscopic Clearance | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| lymphNodeInvolvement | I | 0..1 | code | Lymph node involvement PresentAbsent (Required) If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| lymphNodesDetails | 0..* | string | Site(s) and numbers of lymph nodes | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| extramuralTumourDeposits | 0..1 | code | Isolated extra-mural tumour deposits PresentAbsent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| apicalNodeInvolvement | 0..1 | code | Apical node involvement PresentAbsent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| venousSmallVesselInvasion | 0..1 | string | Venous and small vessel invasion | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| intramuralVeinInvasion | 1..1 | code | Intramural vein invasion NotIdentifiedPresent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| extramuralVeinInvasion | 1..1 | code | Extramural vein invasion NotIdentifiedPresent (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| smallVesselInvasion | 1..1 | code | Small vessel invasion NotIdentifiedPresentPresentExtensive (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| perineuralInvasion | 1..1 | code | Perineural invasion NotIdentifiedPresentPresentExtensive (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| histoConfDistMetastases | I | 1..1 | code | Histologically confirmed distant metastases PresentAbsent (Required) If histologically confirmed distant metastases are present then the sites are to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| histoConfDistMetastasesSite | 0..1 | string | Histologically confirmed distant metastases - site | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| relCoexistPathabnorm | I | 1..* | code | Relevant coexistent pathological abnormalities CoexistentPathologicalAbnormalities (Required) If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded. If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded. | micro.related[type:='has-member'].target→Observation[code value[x] := $value] |
| polypDetails | 0..1 | string | Polyp details (type, number, polyposis syndrome criteria met etc) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| dysplasia | 0..1 | code | Dysplasia Dysplasia (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| otherAbnormality | 0..1 | string | Other abnormality | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| microResidualTumourStatus | 1..1 | string | Microscopic residual tumour status (completeness of resection) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| neoadjuvantTherapy | 0..1 | code | Response to neoadjuvant therapy ResponseToNeoadjuvantTherapy (Required) | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| microComments | 0..1 | string | Microscopic comments | micro.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| ancillaryTests | 0..1 | Element | Ancillary test findings | ancillary := dr.result→Observation[code := %map-codes] | |
| mismatchRepairEnz | 1..1 | Mismatch repair enzymes | |||
| mlh1 | 0..1 | code | MLH-1 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| pms2 | 0..1 | code | PMS-2 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msh2 | 0..1 | code | MSH-2 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msh6 | 0..1 | code | MSH-6 StainType (Required) | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| comments | 0..1 | string | Mismatch repair enzyme comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| msi | I | 0..1 | Element | Microsatellite instability (MSI) | |
| code | I | 0..1 | code | Microsatellite instability (MSI) UnstableStable (Required) If MSI unstable, record laboratory performing test and report number If MSI stable, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | Microsatellite instability (MSI) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | MSI laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| braf | I | 0..1 | Element | BRAF (V600E mutation) | |
| code | I | 0..1 | code | BRAF (V600E mutation) MutatedWildtype (Required) If BRAF mutated, record laboratory performing test and report number If BRAF wild type, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | BRAF (V600E mutation) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | BRAF (V600E mutation) laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| kras | I | 0..1 | Element | KRAS gene mutation (codons 12 and 13) | |
| code | I | 0..1 | code | KRAS gene mutation (codons 12 and 13) MutatedWildtype (Required) If KRAS wild type, record laboratory performing test and report number If KRAS mutated, record laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] |
| comments | 0..1 | string | KRAS gene mutation (codons 12 and 13) comments | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| labDetails | 0..1 | string | KRAS gene mutation (codons 12 and 13) laboratory performing test and report number | ancillary.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| synthesisOverview | 0..1 | Element | Synthesis and Overview | synthesis := dr.result→Observation[code := %map-codes] | |
| tumourStage | 1..1 | string | Tumour stage | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageT | 0..1 | code | T CrcTumourStageT (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageN | 0..1 | code | N CrcTumourStageN (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageM | 0..1 | code | M CrcTumourStageM (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStageGrouping | 1..1 | code | Stage grouping TumourStageGrouping (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| tumourStagingSystem | 1..1 | string | Year and/or edition of staging system | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| residualTumourStatus | 1..1 | string | Residual tumour status ResidualTumourStatus (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| diagnosticSummary | Σ | 0..1 | string | Diagnostic summary | dr[conclusion := $value] |
| newPrimaryOrRecurrence | 0..1 | code | New primary cancer or recurrence NewCancerOrRecurrence (Required) | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| newDescription | 0..1 | string | Describe | ||
| overarchingComment | 0..1 | string | Overarching comment | synthesis.related[type:='has-member'].target→Observation[code value[x] := $value] | |
| Documentation for this format | |||||
| Path | Definition | Type | Reference |
|---|---|---|---|
| Colorectal.preAnalytic.perforation | A code that indicates whether perforation is present | Required | PresentAbsentNotstated |
| Colorectal.preAnalytic.natureOfPerforation | A code that indicates the type of perforation | Required | NehtaNatureOfPerforation |
| Colorectal.preAnalytic.clinicalObstruction | A code that indicates whether a clinical obstruction is present | Required | PresentAbsentNotstated |
| Colorectal.preAnalytic.tumourLocation | A code that indicates the antomical location of the tumour from a given list | Required | ColorectalCancerTumourLocation |
| Colorectal.preAnalytic.typeOfOperation | A code that indicates the type of operation | Required | ColorectalCancerOperationType |
| Colorectal.preAnalytic.anteriorResectionType | A code that idicates the type of anterior resection | Required | HiLowUltralow |
| Colorectal.preAnalytic.preoperativeRadiotherapy | A code that indicates whether pre-operative radiotherapy was used | Required | YesNoNotStated |
| Colorectal.preAnalytic.typeOfCourse | A code that indicates the type of course of pre-operative radiotherapy | Required | TypeOfCourse |
| Colorectal.preAnalytic.newPrimaryOrRecurrence | A code that indicates whether a new primary cancer or an recurrence | Required | NehtaCancerPrimaryOrRecurrence |
| Colorectal.macro.tumourSite | A code that indicates the site of the tumour | Required | ColorectalCancerTumourLocation |
| Colorectal.macro.tumourPerforation | A code that indicates the presence or absence of a tumour perforation | Required | PresentAbsent |
| Colorectal.macro.relToAntPeritonealReflection | A code that indicates the site of tumour in relation to the anterior level of the peritoneal reflection | Required | NehtaRelAnteriorPeritonealReflection |
| Colorectal.macro.intactnessOfMesorectum | A code that indicates the intactness of the mesorectum | Required | MesorectumIntactness |
| Colorectal.macro.peritoneum | A code that indicates the tumour invovlement in the peritoneum | Required | NehtaPeritoneumInvasion |
| Colorectal.macro.lymphNodes | A code that indicates if lymph nodes were received | Required | ReceivedNotreceived |
| Colorectal.macro.polyps | A code that indicates the presence or absence of polyp(s) | Required | PresentAbsent |
| Colorectal.micro.tumourType | A code from the WHO Calssification that indicates the tumour type | Required | TumourType |
| Colorectal.micro.histologicalGrade | A code that indicates the histological grade of the tumour | Required | HistologicalGrade |
| Colorectal.micro.maxDegreeLocalInvasion | A code that indicates the maximum degree of local invasion into or through the bowel wall | Required | DegreeInvasionBowelWall |
| Colorectal.micro.proximalOrDistalResectionMargins | A code that indicates involvement of the proximal or distal resection (cut-end) margins | Required | CRCInvolvedNotinvolved |
| Colorectal.micro.involvedMargins | A code that indicates the involvement at the margins | Required | DistalProximal |
| Colorectal.micro.nonperitonealisedCircumMargin | A code that indicates the status of the nonperitonealised circumferential margin in rectal tumours | Required | InvolvedNotinvolved |
| Colorectal.micro.lymphNodeInvolvement | A code that indicates lymph node involvement | Required | PresentAbsent |
| Colorectal.micro.extramuralTumourDeposits | A code that indicates the presence or absence of isolated extra-mural tumour deposits. | Required | PresentAbsent |
| Colorectal.micro.apicalNodeInvolvement | A code that indicates apical node involvement | Required | PresentAbsent |
| Colorectal.micro.intramuralVeinInvasion | A code that indicates intramural vein invasion | Required | NotIdentifiedPresent |
| Colorectal.micro.extramuralVeinInvasion | A code that indicates extramural vein invasion | Required | NotIdentifiedPresent |
| Colorectal.micro.smallVesselInvasion | A code that indicates small vessel invasion | Required | NotIdentifiedPresentPresentExtensive |
| Colorectal.micro.perineuralInvasion | A code that indicates perineural invasion | Required | NotIdentifiedPresentPresentExtensive |
| Colorectal.micro.histoConfDistMetastases | A code that indicates the presence or absence of histologically confirmed distant metastases | Required | PresentAbsent |
| Colorectal.micro.relCoexistPathabnorm | A code that indicates the relevant coexistent pathological abnormalities | Required | CoexistentPathologicalAbnormalities |
| Colorectal.micro.dysplasia | A code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalities | Required | Dysplasia |
| Colorectal.micro.neoadjuvantTherapy | A code that indicates the response to neoadjuvant therapy | Required | ResponseToNeoadjuvantTherapy |
| Colorectal.ancillaryTests.mlh1 | A code that indicates MLH-1 testing | Required | StainType |
| Colorectal.ancillaryTests.pms2 | A code that indicates PMS-2 testing | Required | StainType |
| Colorectal.ancillaryTests.msh2 | A code that indicates MSH-2 testing | Required | StainType |
| Colorectal.ancillaryTests.msh6 | A code that indicates MSH-6 testing | Required | StainType |
| Colorectal.ancillaryTests.msi.code | A code that indicates Microsatellite instability (MSI) | Required | UnstableStable |
| Colorectal.ancillaryTests.braf.code | A code that indicates the BRAF (V600E mutation) | Required | MutatedWildtype |
| Colorectal.ancillaryTests.kras.code | A code that indicates the KRAS gene mutation (codons 12 and 13) | Required | MutatedWildtype |
| Colorectal.synthesisOverview.tumourStageT | A code that records tumour stage T | Required | CrcTumourStageT |
| Colorectal.synthesisOverview.tumourStageN | A code that records tumour stage N | Required | CrcTumourStageN |
| Colorectal.synthesisOverview.tumourStageM | A code that records tumour stage M | Required | CrcTumourStageM |
| Colorectal.synthesisOverview.tumourStageGrouping | A code that records tumour stage grouping | Required | TumourStageGrouping |
| Colorectal.synthesisOverview.residualTumourStatus | An R code that records the residual tumour status | Required | ResidualTumourStatus |
| Colorectal.synthesisOverview.newPrimaryOrRecurrence | A code that records whether a new primary cancer or a recurrence | Required | NewCancerOrRecurrence |
todo;
© HL7.org 2011+. FHIR DSTU2 (v1.2.0-7447) generated on Fri, Dec 11, 2015 17:40+1100.
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