Breast Radiology Reporting - 1st for comment ballot

This page is part of the Breast Radiology Report (v0.1.0: Comment Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Example: BreastAbnormalityExample1


<Observation xmlns="http://hl7.org/fhir">
  <id value="BreastAbnormalityExample1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/breast-radiology/StructureDefinition/breastrad-BreastAbnormality"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
This is an example Breast Abnormality Observation.<br/>
<br/>
<b>Id</b>: BreastAbnormalityExample1<br/>
<b>Status</b>: 'Final'<br/>
<b>Code</b>: [http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS] 'BreastAbnormalityObservationCode'<br/>
<b>Subject</b>: Reference to subject of exam<br/>
<b>AbnormalityDensity [Component]</b>: CentralLucent<br/>
<b>AsymmetryTypes [Component]</b>: DensityFocalAsymmetry<br/>
<b>BiRadCode [Component]</b>: BIRAD2Benign<br/>
<b>CalcificationType [Component]</b>: Spherical<br/>
<b>Change [Component]</b>: DecreaseInCalcifications<br/>
<b>CystTypes [Component]</b>: ComplexCyst<br/>
<b>ForeignBody [Component]</b>: BiopsyClip<br/>
<b>Hilum [Component]</b>: HilumFatty<br/>
<b>LymphNodeQualifiers [Component]</b>: LevelILymphNode<br/>
<b>Margin [Component]</b>: AngularMargin<br/>
<b>MassTypes [Component]</b>: xxyyz<br/>
<b>NodeTypes [Component]</b>: AxillaryNode<br/>
<b>Shape [Component]</b>: IrregularShape<br/>
<b>Vascularity [Component]</b>: Adjacent<br/>
<b>Wall [Component]</b>: IrregularInternalWall<br/>
<b>MaxLength [Component]</b>: 1 mm<br/>
<b>MaxWidth [Component]</b>: 2 mm<br/>
</div>
  </text>
  <status value="final"/>
  <code>
    <coding>
      <system
              value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
      <code value="BreastAbnormalityObservationCode"/>
    </coding>
  </code>
  <subject>
    <display value="Reference to subject of exam"/>
  </subject>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="AbnormalityDensity"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-AbnormalityDensityCS"/>
        <code value="CentralLucent"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="AsymmetryTypes"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-AsymmetryTypesCS"/>
        <code value="DensityFocalAsymmetry"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="BiRadCode"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BiRadCodeCS"/>
        <code value="BIRAD2Benign"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="CalcificationType"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-CalcificationTypeCS"/>
        <code value="Spherical"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Change"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-ChangeCS"/>
        <code value="DecreaseInCalcifications"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="CystTypes"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-CystTypesCS"/>
        <code value="ComplexCyst"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="ForeignBody"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-ForeignBodyCS"/>
        <code value="BiopsyClip"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Hilum"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-HilumCS"/>
        <code value="HilumFatty"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="LymphNodeQualifiers"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-LymphNodeQualifiersCS"/>
        <code value="LevelILymphNode"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Margin"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-MarginCS"/>
        <code value="AngularMargin"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="MassTypes"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-MassTypesCS"/>
        <code value="IntraductalMass"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="NodeTypes"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-NodeTypesCS"/>
        <code value="AxillaryNode"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Shape"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-ShapeCS"/>
        <code value="IrregularShape"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Vascularity"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-VascularityCS"/>
        <code value="Adjacent"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="Wall"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-WallCS"/>
        <code value="IrregularInternalWall"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="MaxLength"/>
      </coding>
    </code>
    <valueQuantity>
      <value value="1"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </valueQuantity>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/breast-radiology/CodeSystem/breastrad-BreastAbnormalityCodesCS"/>
        <code value="MaxWidth"/>
      </coding>
    </code>
    <valueQuantity>
      <value value="2"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </valueQuantity>
  </component>
</Observation>