Cancer Pathology Data Sharing
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This page is part of the Sharing eCC Data from Pathology Labs to EHR (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.0.1. For a full list of available versions, see the Directory of published versions

Example Observation: Nuclear Pleomorphism Observation Example

Page standards status: Informative

Generated Narrative: Observation observation-nuclear-pleomorphism

identifier: https://cap.org/eCC/urn:uuid:77d0563d-3685-4316-9a81-fa7d04d0d8d2

status: Final

category: Question

code: Nuclear Pleomorphism

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: Alaska Driver's License#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Score 2 (Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape)

derivedFrom: Observation ?Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)