minimal Common Oncology Data Elements (mCODE) Implementation Guide
3.0.0 - STU3 Release United States of America flag

This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v3.0.0: STU 3) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: us-core-diagnosticreport-lab-jenny-m - XML Representation

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="us-core-diagnosticreport-lab-jenny-m"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h2><span title="Codes: {http://loinc.org 22637-3}">Pathology report final diagnosis Narrative</span> (<span title="Codes: {http://terminology.hl7.org/CodeSystem/v2-0074 LAB}">Laboratory</span>) </h2><table class="grid"><tr><td>Subject</td><td><b>Jenny M </b> female, DoB: 1965-01-01 ( Medical Record Number: MRN1234 (use: USUAL))</td></tr><tr><td>When For</td><td>2018-04-01 00:00:00+0000</td></tr><tr><td>Reported</td><td>2018-04-05 00:00:00+0000</td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-us-core-observation-lab-tumor-invasion-jenny-m.html"><span title="Codes: {http://snomed.info/sct 370052007}">Status of invasion by tumor</span></a></td><td><span title="Codes: {http://snomed.info/sct 260385009}">Negative (qualifier value)</span></td><td>2018-04-01 00:00:00+0000</td></tr><tr><td><a href="Observation-us-core-observation-lab-tumor-margins-jenny-m.html"><span title="Codes: {http://loinc.org 44669-0}">Margin involvement in Breast tumor</span></a></td><td><span title="Codes: {http://loinc.org LA27151-2}">Uninvolved by invasive carcinoma</span></td><td>2018-04-01 00:00:00+0000</td></tr><tr><td><a href="Observation-us-core-observation-lab-sentinel-nodes-jenny-m.html"><span title="Codes: {http://loinc.org 92832-5}">Sentinel lymph nodes with metastasis [#] in Cancer specimen</span></a></td><td/><td>2018-04-01 00:00:00+0000</td></tr><tr><td><a href="Observation-tumor-size-jenny-m.html"><span title="Codes: {http://loinc.org 21889-1}">Size Tumor</span></a></td><td/><td>2018-04-01 00:00:00+0000</td></tr><tr><td><a href="Observation-us-core-observation-lab-tumor-dcis-jenny-m.html"><span title="Codes: {http://loinc.org 85336-6}">DCIS intraductal extension in Breast cancer specimen Qualitative by Light microscopy</span></a></td><td><span title="Codes: {http://loinc.org LA27261-9}">DCIS present with extensive intraductal component (EIC)</span></td><td>2018-04-01 00:00:00+0000</td></tr><tr><td><a href="Observation-tumor-marker-test-her2-jenny-m.html"><span title="Codes: {http://loinc.org 48676-1}">HER2 [Interpretation] in Tissue</span></a></td><td><span title="Codes: {http://loinc.org LA6577-6}">Negative</span></td><td>2018-03-10</td></tr><tr><td><a href="Observation-tumor-marker-test-er-jenny-m.html"><span title="Codes: {http://loinc.org 85337-4}">Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain</span></a></td><td><span title="Codes: {http://loinc.org LA6576-8}">Positive</span></td><td>2018-03-10</td></tr><tr><td><a href="Observation-tumor-marker-test-pr-jenny-m.html"><span title="Codes: {http://loinc.org 85339-0}">Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain</span></a></td><td><span title="Codes: {http://loinc.org LA6577-6}">Negative</span></td><td>2018-03-10</td></tr><tr><td><a href="Observation-us-core-observation-lab-tumor-grade-jenny-m.html"><span title="Codes: {http://loinc.org 44648-4}">Histologic grade [Score] in Breast cancer specimen Qualitative by Nottingham</span></a></td><td><span title="Codes: {http://loinc.org LA27824-4}">Nottingham grade 2</span></td><td>2018-04-01 00:00:00+0000</td></tr></table></div>
  </text>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="LAB"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="22637-3"/>
      <display value="Pathology report final diagnosis Narrative"/>
    </coding>
  </code>
  <subject>
    <reference value="Patient/cancer-patient-jenny-m"/>
  </subject>
  <effectiveDateTime value="2018-04-01T00:00:00Z"/>
  <issued value="2018-04-05T00:00:00Z"/>
  <performer>
    <reference value="Practitioner/us-core-practitioner-owen-oncologist"/>
  </performer>
  <resultsInterpreter>
    <reference value="Practitioner/us-core-practitioner-peter-pathologist"/>
  </resultsInterpreter>
  <specimen>
    <reference value="Specimen/tumor-specimen-left-breast-jenny-m"/>
  </specimen>
  <result>
    <reference
               value="Observation/us-core-observation-lab-tumor-invasion-jenny-m"/>
  </result>
  <result>
    <reference
               value="Observation/us-core-observation-lab-tumor-margins-jenny-m"/>
  </result>
  <result>
    <reference
               value="Observation/us-core-observation-lab-sentinel-nodes-jenny-m"/>
  </result>
  <result>
    <reference value="Observation/tumor-size-jenny-m"/>
  </result>
  <result>
    <reference
               value="Observation/us-core-observation-lab-tumor-dcis-jenny-m"/>
  </result>
  <result>
    <reference value="Observation/tumor-marker-test-her2-jenny-m"/>
  </result>
  <result>
    <reference value="Observation/tumor-marker-test-er-jenny-m"/>
  </result>
  <result>
    <reference value="Observation/tumor-marker-test-pr-jenny-m"/>
  </result>
  <result>
    <reference
               value="Observation/us-core-observation-lab-tumor-grade-jenny-m"/>
  </result>
</DiagnosticReport>