minimal Common Oncology Data Elements (mCODE) Implementation Guide
2.1.0 - STU 2.1 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 (v2.1.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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

Raw json | Download


{
  "resourceType" : "DiagnosticReport",
  "id" : "us-core-diagnosticreport-lab-jenny-m",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<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>, <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v2-0074 SP}\">Surgical Pathology</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td><b>Jenny M </b> female, DoB: 1965-01-01 ( Medical Record Number: MRN1234\u00a0(use:\u00a0USUAL))</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>"
  },
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "LAB"
        }
      ]
    },
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "SP",
          "display" : "Surgical Pathology"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "22637-3",
        "display" : "Pathology report final diagnosis Narrative"
      }
    ]
  },
  "subject" : {
    "reference" : "Patient/cancer-patient-jenny-m"
  },
  "effectiveDateTime" : "2018-04-01T00:00:00Z",
  "issued" : "2018-04-05T00:00:00Z",
  "performer" : [
    {
      "reference" : "Organization/us-core-organization-physician-services-inc"
    }
  ],
  "resultsInterpreter" : [
    {
      "reference" : "Practitioner/us-core-practitioner-peter-pathologist"
    }
  ],
  "specimen" : [
    {
      "reference" : "Specimen/tumor-specimen-left-breast-jenny-m"
    }
  ],
  "result" : [
    {
      "reference" : "Observation/us-core-observation-lab-tumor-invasion-jenny-m"
    },
    {
      "reference" : "Observation/us-core-observation-lab-tumor-margins-jenny-m"
    },
    {
      "reference" : "Observation/us-core-observation-lab-sentinel-nodes-jenny-m"
    },
    {
      "reference" : "Observation/tumor-size-jenny-m"
    },
    {
      "reference" : "Observation/us-core-observation-lab-tumor-dcis-jenny-m"
    },
    {
      "reference" : "Observation/tumor-marker-test-her2-jenny-m"
    },
    {
      "reference" : "Observation/tumor-marker-test-er-jenny-m"
    },
    {
      "reference" : "Observation/tumor-marker-test-pr-jenny-m"
    },
    {
      "reference" : "Observation/us-core-observation-lab-tumor-grade-jenny-m"
    }
  ]
}