minimal Common Oncology Data Elements (mCODE) Implementation Guide
2.0.0 - STU 2

This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v2.0.0: 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

Example DiagnosticReport: us-core-diagnosticreport-lab-jenny-m

Pathology report final diagnosis Narrative (Laboratory, Surgical Pathology)

SubjectJenny M ?? 1965-01-01 ( Medical Record Number: MRN1234 (USUAL))
When For2018-04-01T00:00:00Z
Reported2018-04-05T00:00:00Z

Report Details

CodeValueWhen For
Status of invasion by tumorNegative (qualifier value)2018-04-01T00:00:00Z
Margin involvement in Breast tumorUninvolved by invasive carcinoma2018-04-01T00:00:00Z
Sentinel lymph nodes with metastasis [#] in Cancer specimen2018-04-01T00:00:00Z
Size Tumor2018-04-01T00:00:00Z
DCIS intraductal extension in Breast cancer specimen Qualitative by Light microscopyDCIS present with extensive intraductal component (EIC)2018-04-01T00:00:00Z
HER2 [Interpretation] in TissueNegative2018-03-10
Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stainPositive2018-03-10
Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stainNegative2018-03-10
Histologic grade [Score] in Breast cancer specimen Qualitative by NottinghamNottingham grade 22018-04-01T00:00:00Z

Notes:

Instance: us-core-diagnosticreport-lab-jenny-m
InstanceOf: USCoreDiagnosticReportProfileLaboratoryReporting
Title: "us-core-diagnosticreport-lab-jenny-m"
Description: "Extended example: example of pathology findings represented as a DiagnosticReport resource."
Usage: #example
* status = #final
* category[0] = http://terminology.hl7.org/CodeSystem/v2-0074#LAB
* category[+] = http://terminology.hl7.org/CodeSystem/v2-0074#SP "Surgical Pathology"
* code = http://loinc.org#22637-3 "Pathology report final diagnosis Narrative"
* subject = Reference(cancer-patient-jenny-m)
* effectiveDateTime = "2018-04-01T00:00:00Z"
* issued = "2018-04-05T00:00:00Z"
* performer = Reference(us-core-organization-physician-services-inc)
* resultsInterpreter = Reference(us-core-practitioner-peter-pathologist)
* specimen = Reference(tumor-specimen-left-breast-jenny-m)
* result[0] = Reference(us-core-observation-lab-tumor-invasion-jenny-m)
* result[+] = Reference(us-core-observation-lab-tumor-margins-jenny-m)
* result[+] = Reference(us-core-observation-lab-sentinel-nodes-jenny-m)
* result[+] = Reference(tumor-size-jenny-m)
* result[+] = Reference(us-core-observation-lab-tumor-dcis-jenny-m)
* result[+] = Reference(tumor-marker-test-her2-jenny-m)
* result[+] = Reference(tumor-marker-test-er-jenny-m)
* result[+] = Reference(tumor-marker-test-pr-jenny-m)
* result[+] = Reference(us-core-observation-lab-tumor-grade-jenny-m)