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 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 Bundle: mcode-patient-bundle-jenny-m

Bundle mcode-patient-bundle-jenny-m of type collection

Entry 1 - fullUrl = http://example.org/fhir/Patient/cancer-patient-jenny-m

Resource Patient:

Jenny M Female, DoB: 1965-01-01 ( Medical Record Number: MRN1234 (use: USUAL))

Entry 2 - fullUrl = http://example.org/fhir/Condition/primary-cancer-condition-jenny-m

Resource Condition:

Generated Narrative: Condition

Resource Condition "primary-cancer-condition-jenny-m"

Profile: Primary Cancer Condition Profile

Histology-Morphology-Behavior Extension: Infiltrating duct carcinoma (morphologic abnormality) (SNOMED CT#82711006)

clinicalStatus: Remission (Condition Clinical Status Codes#remission)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem List Item (Condition Category Codes#problem-list-item)

code: Primary malignant neoplasm of female left breast (disorder) (SNOMED CT#353431000119107)

subject: See above (Patient/cancer-patient-jenny-m)

onset: 2018-03-16

Stages

-SummaryAssessmentType
*American Joint Committee on Cancer stage IIIC (qualifier value) (SNOMED CT#1222806003)See above (Observation/tnm-clinical-stage-group-jenny-m)American Joint Commission on Cancer, Cancer Staging Manual, 8th edition neoplasm staging system (tumor staging) (SNOMED CT#897275008)

Entry 3 - fullUrl = http://example.org/fhir/MedicationRequest/cancer-related-medication-request-cyclophosphamide-jenny-m

Resource MedicationRequest:

Generated Narrative: MedicationRequest

Resource MedicationRequest "cancer-related-medication-request-cyclophosphamide-jenny-m"

Profile: Cancer-Related Medication Request Profile

Procedure Intent Extension: Curative - procedure intent (qualifier value) (SNOMED CT#373808002)

status: ACTIVE

intent: ORDER

category: Outpatient (MedicationRequest Category Codes#outpatient)

subject: See above (Patient/cancer-patient-jenny-m)

authoredOn: 2018-04-12

requester: See above (Practitioner/us-core-practitioner-owen-oncologist)

dosageInstruction

Entry 4 - fullUrl = http://example.org/fhir/MedicationRequest/cancer-related-medication-request-doxorubicin-jenny-m

Resource MedicationRequest:

Generated Narrative: MedicationRequest

Resource MedicationRequest "cancer-related-medication-request-doxorubicin-jenny-m"

Profile: Cancer-Related Medication Request Profile

Procedure Intent Extension: Curative - procedure intent (qualifier value) (SNOMED CT#373808002)

status: ACTIVE

intent: ORDER

category: Outpatient (MedicationRequest Category Codes#outpatient)

subject: See above (Patient/cancer-patient-jenny-m)

authoredOn: 2018-04-12

requester: See above (Practitioner/us-core-practitioner-owen-oncologist)

dosageInstruction

Entry 5 - fullUrl = http://example.org/fhir/MedicationRequest/cancer-related-medication-request-paclitaxel-jenny-m

Resource MedicationRequest:

Generated Narrative: MedicationRequest

Resource MedicationRequest "cancer-related-medication-request-paclitaxel-jenny-m"

Profile: Cancer-Related Medication Request Profile

Procedure Intent Extension: Curative - procedure intent (qualifier value) (SNOMED CT#373808002)

status: ACTIVE

intent: ORDER

category: Outpatient (MedicationRequest Category Codes#outpatient)

subject: See above (Patient/cancer-patient-jenny-m)

authoredOn: 2018-04-12

requester: See above (Practitioner/us-core-practitioner-owen-oncologist)

dosageInstruction

Entry 6 - fullUrl = http://example.org/fhir/MedicationRequest/cancer-related-medication-request-anastrozole-jenny-m

Resource MedicationRequest:

Generated Narrative: MedicationRequest

Resource MedicationRequest "cancer-related-medication-request-anastrozole-jenny-m"

Profile: Cancer-Related Medication Request Profile

Procedure Intent Extension: Curative - procedure intent (qualifier value) (SNOMED CT#373808002)

status: ACTIVE

intent: ORDER

category: Community (MedicationRequest Category Codes#community)

subject: See above (Patient/cancer-patient-jenny-m)

authoredOn: 2018-09-30

requester: See above (Practitioner/us-core-practitioner-owen-oncologist)

dosageInstruction

Entry 7 - fullUrl = http://example.org/fhir/Observation/cancer-disease-status-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "cancer-disease-status-jenny-m"

Profile: Cancer Disease Status Profile

Cancer Disease Status Evidence Type Extension: Imaging (procedure) (SNOMED CT#363679005)

status: FINAL

code: Cancer Disease Progression (LOINC#97509-4)

subject: See above (Patient/cancer-patient-jenny-m)

focus: See above (Condition/primary-cancer-condition-jenny-m)

effective: 2018-11-01

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Patient's condition improved (finding) (SNOMED CT#268910001)

Entry 8 - fullUrl = http://example.org/fhir/Observation/genomic-variant-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "genomic-variant-jenny-m"

Profile: Genomic Variant Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Genetic variant assessment (LOINC#69548-6)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-15

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Present (LOINC#LA9633-4)

method: Sequencing (LOINC#LA26398-0)

component

code: 48018-6 (LOINC#48018-6)

value: PALB2 (HUGO Gene Nomenclature Committee Genes#HGNC:26144)

component

code: 81252-9 (LOINC#81252-9)

value: NM_024675.3(PALB2):c.3549C>A (p.Tyr1183Ter) (ClinVar Variant ID#128144)

component

code: 81290-9 (LOINC#81290-9)

value: NC_000016.10:g.23603471G>T (Human Genome Variation Society nomenclature#NC_000016.10:g.23603471G>T)

component

code: 48002-0 (LOINC#48002-0)

value: Somatic (LOINC#LA6684-0)

Entry 9 - fullUrl = http://example.org/fhir/DiagnosticReport/genomics-report-jenny-m

Resource DiagnosticReport:

Genetic analysis report (Genetics)

SubjectJenny M female, DoB: 1965-01-01 ( Medical Record Number: MRN1234 (use: USUAL))
When For2018-03-15
Reported2020-03-15 00:00:01+0000

Report Details

CodeValueWhen ForReported
Genetic variant assessmentPresent2018-03-15
DNA region of interest panel2018-03-152018-03-15 00:00:01+0000

Entry 10 - fullUrl = http://example.org/fhir/Procedure/cancer-related-surgical-procedure-jenny-m

Resource Procedure:

Generated Narrative: Procedure

Resource Procedure "cancer-related-surgical-procedure-jenny-m"

Profile: Cancer-Related Surgical Procedure Profile

Procedure Intent Extension: Curative - procedure intent (qualifier value) (SNOMED CT#373808002)

status: COMPLETED

code: Excision of part of breast (procedure) (SNOMED CT#64368001)

subject: See above (Patient/cancer-patient-jenny-m)

bodySite: Left breast structure (body structure) (SNOMED CT#80248007)

Entry 11 - fullUrl = http://example.org/fhir/Observation/cancer-related-comorbidities-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "cancer-related-comorbidities-jenny-m"

Profile: Comorbidities Profile

Related Condition Extension: Condition/us-core-condition-depression-jenny-m

Related Condition Extension: Condition/us-core-condition-anxiety-jenny-m

Related Condition Extension: Condition/us-core-condition-hypertension-jenny-m

Related Condition Absent Extension: Obesity (disorder) (SNOMED CT#414916001)

Related Condition Absent Extension: Disorder of lung (disorder) (SNOMED CT#19829001)

status: FINAL

code: 398192003 (SNOMED CT#398192003)

subject: See above (Patient/cancer-patient-jenny-m)

focus: See above (Condition/primary-cancer-condition-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

Entry 12 - fullUrl = http://example.org/fhir/Procedure/radiotherapy-treatment-summary-chest-wall-jenny-m

Resource Procedure:

Generated Narrative: Procedure

Resource Procedure "radiotherapy-treatment-summary-chest-wall-jenny-m"

Profile: Radiotherapy Course Summary Profile

Radiotherapy Number of Sessions Extension: 31

Procedure Intent Extension: Curative - procedure intent (SNOMED CT#373808002)

Radiotherapy Modality And Technique Extension

url

Radiotherapy Modality Extension

value: External beam radiation therapy using photons (procedure) (SNOMED CT#1156506007)

url

Radiotherapy Technique Extension

value: Volumetric Modulated Arc Therapy (procedure) (SNOMED CT#1156530009)

Radiotherapy Modality And Technique Extension

url

Radiotherapy Modality Extension

value: Teleradiotherapy using electrons (SNOMED CT#45643008)

url

Radiotherapy Technique Extension

value: Three dimensional external beam radiation therapy (procedure) (SNOMED CT#1162782007)

Radiotherapy Dose Delivered To Volume Extension

url

volume

value: BodyStructure/jenny-m-chest-wall-treatment-volume

url

totalDoseDelivered

value: 6000 cGy (Details: UCUM code cGy = 'cGy')

url

fractionsDelivered

value: 30

Radiotherapy Dose Delivered To Volume Extension

url

volume

value: BodyStructure/jenny-m-chest-wall-lymph-nodes-treatment-volume

url

totalDoseDelivered

value: 5000 cGy (Details: UCUM code cGy = 'cGy')

url

fractionsDelivered

value: 25

status: COMPLETED

category: Radiation oncology AND/OR radiotherapy (procedure) (SNOMED CT#108290001)

code: 1217123003 (SNOMED CT#1217123003)

subject: See above (Patient/cancer-patient-jenny-m)

bodySite: Chest Wall Structure (body structure) (SNOMED CT#78904004)

Entry 13 - fullUrl = http://example.org/fhir/Observation/tnm-clinical-stage-group-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tnm-clinical-stage-group-jenny-m"

Profile: TNM Stage Group Profile

status: FINAL

code: Clinical TNM stage grouping (SNOMED CT#399537006)

subject: See above (Patient/cancer-patient-jenny-m)

focus: See above (Condition/primary-cancer-condition-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: American Joint Committee on Cancer stage IIB (qualifier value) (SNOMED CT#1222769001)

method: American Joint Commission on Cancer, Cancer Staging Manual, 8th edition neoplasm staging system (tumor staging) (SNOMED CT#897275008)

hasMember:

Entry 14 - fullUrl = http://example.org/fhir/Observation/tnm-clinical-primary-tumor-category-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tnm-clinical-primary-tumor-category-jenny-m"

Profile: TNM Primary Tumor Category Profile

status: FINAL

code: cT category (SNOMED CT#399504009)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: American Joint Committee on Cancer cT3 (qualifier value) (SNOMED CT#1228938002)

method: American Joint Commission on Cancer, Cancer Staging Manual, 8th edition neoplasm staging system (tumor staging) (SNOMED CT#897275008)

Entry 15 - fullUrl = http://example.org/fhir/Observation/tnm-clinical-regional-nodes-category-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tnm-clinical-regional-nodes-category-jenny-m"

Profile: TNM Regional Nodes Category Profile

status: FINAL

code: cN category (SNOMED CT#399534004)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: American Joint Committee on Cancer cN0 (qualifier value) (SNOMED CT#1229967007)

method: American Joint Commission on Cancer, Cancer Staging Manual, 8th edition neoplasm staging system (tumor staging) (SNOMED CT#897275008)

Entry 16 - fullUrl = http://example.org/fhir/Observation/tnm-clinical-distant-metastases-category-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tnm-clinical-distant-metastases-category-jenny-m"

Profile: TNM Distant Metastases Category Profile

status: FINAL

code: cM category (SNOMED CT#399387003)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: American Joint Committee on Cancer cM0 (qualifier value) (SNOMED CT#1229901006)

method: American Joint Commission on Cancer, Cancer Staging Manual, 8th edition neoplasm staging system (tumor staging) (SNOMED CT#897275008)

Entry 17 - fullUrl = http://example.org/fhir/Specimen/human-specimen-left-breast-jenny-m

Resource Specimen:

Generated Narrative: Specimen

Resource Specimen "human-specimen-left-breast-jenny-m"

Profile: Human Specimen Profile

status: AVAILABLE

type: Tissue (specimenType#TISS)

subject: See above (Patient/cancer-patient-jenny-m)

Collections

-CollectorBodySite
*See above (Practitioner/us-core-practitioner-owen-oncologist)Left breast structure (body structure) (SNOMED CT#80248007)

Processings

-Time[x]
*2018-03-06

Entry 18 - fullUrl = http://example.org/fhir/Observation/genomic-region-studied-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "genomic-region-studied-jenny-m"

Profile: Genomic Region Studied Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: DNA region of interest panel (LOINC#53041-0)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-15

issued: Mar 15, 2018, 12:00:01 AM

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

Components

-CodeValue[x]
*Gene studied [ID] (LOINC#48018-6)BRCA1 (HUGO Gene Nomenclature Committee Genes#1100; HUGO Gene Nomenclature Committee Genes#1101 "BRCA2"; HUGO Gene Nomenclature Committee Genes#1748 "CDH1"; HUGO Gene Nomenclature Committee Genes#26144 "PALB2"; HUGO Gene Nomenclature Committee Genes#9588 "PTEN"; HUGO Gene Nomenclature Committee Genes#11389 "STK11"; HUGO Gene Nomenclature Committee Genes#11998 "TP53")

Entry 19 - fullUrl = http://example.org/fhir/Observation/ecog-performance-status-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "ecog-performance-status-jenny-m"

Profile: ECOG Performance Status Profile

status: FINAL

category: Clinical Test (US Core Observation Category Extension Codes#clinical-test)

code: 89247-1 (LOINC#89247-1)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-12

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: 0

interpretation: Fully active, able to carry on all pre-disease performance without restriction (LOINC#LA9622-7)

method: Physical examination procedure (procedure) (SNOMED CT#5880005)

Entry 20 - fullUrl = http://example.org/fhir/Observation/tumor-marker-test-er-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tumor-marker-test-er-jenny-m"

Profile: Tumor Marker Test Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain (LOINC#85337-4)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-10

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Positive (LOINC#LA6576-8)

Entry 21 - fullUrl = http://example.org/fhir/Observation/tumor-marker-test-pr-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tumor-marker-test-pr-jenny-m"

Profile: Tumor Marker Test Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain (LOINC#85339-0)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-10

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Negative (LOINC#LA6577-6)

Entry 22 - fullUrl = http://example.org/fhir/Observation/tumor-marker-test-her2-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tumor-marker-test-her2-jenny-m"

Profile: Tumor Marker Test Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: HER2 [Interpretation] in Tissue (LOINC#48676-1)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-10

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Negative (LOINC#LA6577-6)

Entry 23 - fullUrl = http://example.org/fhir/Observation/tumor-marker-test-oncotype-dx-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tumor-marker-test-oncotype-dx-jenny-m"

Profile: Tumor Marker Test Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Oncotype DX Breast Recurrence Score Assay (gtr#509910)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-12

performer: Organization/us-core-organization-bedrock-medicine "Bedrock Medicine"

value: 47 Recurrence score (Details: UCUM code 1 = '1')

interpretation: High (ObservationInterpretation#H)

Entry 24 - fullUrl = http://example.org/fhir/Observation/tumor-size-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "tumor-size-jenny-m"

Profile: Tumor Size Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Size Tumor (LOINC#21889-1)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-01 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

method: Gross examination and sampling of tissue specimen (procedure) (SNOMED CT#787377000)

specimen: Specimen/tumor-specimen-left-breast-jenny-m

Components

-CodeValue[x]
*33728-7 (LOINC#33728-7)2.5 centimeters (Details: UCUM code cm = 'cm')

Entry 25 - fullUrl = http://example.org/fhir/Observation/us-core-procedure-biopsy-jenny-m

Resource Procedure:

Generated Narrative: Procedure

Resource Procedure "us-core-procedure-biopsy-jenny-m"

Profile: US Core Procedure Profile

status: COMPLETED

code: Biopsy of breast using ultrasonographic guidance (procedure) (SNOMED CT#723990008)

subject: See above (Patient/cancer-patient-jenny-m)

Performers

-Actor
*Practitioner/us-core-practitioner-mary-obgyn " OBGYN"

bodySite: Left breast structure (body structure) (SNOMED CT#80248007)

Entry 26 - fullUrl = http://example.org/fhir/Observation/bodyweight-jenny-m-2018-03-16

Resource Observation:

Generated Narrative: Observation

Resource Observation "bodyweight-jenny-m-2018-03-16"

Profile: Observation Body Weight Profile

status: FINAL

category: Vital Signs (Observation Category Codes#vital-signs)

code: 29463-7 (LOINC#29463-7)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-06

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: 155 lb (Details: UCUM code [lb_av] = '[lb_av]')

Entry 27 - fullUrl = http://example.org/fhir/Observation/us-core-observation-lab-neutrophils-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-observation-lab-neutrophils-jenny-m"

Profile: US Core Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Neutrophils [#/volume] in Blood (LOINC#26499-4)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-05-20 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: 3000 10*3/uL (Details: UCUM code 10*3/uL = '10*3/uL')

ReferenceRanges

-LowHighAppliesTo
*2500 10*3/uL (Details: UCUM code 10*3/uL = '10*3/uL')5000 10*3/uL (Details: UCUM code 10*3/uL = '10*3/uL')Normal Range (Observation Reference Range Meaning Codes#normal)

Entry 28 - fullUrl = http://example.org/fhir/Organization/us-core-organization-physician-services-inc

Resource Organization:

Generated Narrative: Organization

Resource Organization "us-core-organization-physician-services-inc"

Profile: US Core Organization Profile

active: true

type: Healthcare Provider (Organization type#prov)

name: Physician Services, Inc.

Contacts

-TelecomAddress
*ph: 999-999-9999(WORK)123 Corporate Drive Anytown MA 12345 US

Entry 29 - fullUrl = http://example.org/fhir/Observation/us-core-smokingstatus-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-smokingstatus-jenny-m"

Profile: US Core Smoking Status Observation Profile

status: FINAL

category: Social History (Observation Category Codes#social-history)

code: Tobacco smoking status (LOINC#72166-2)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-16

issued: Mar 16, 2018, 12:00:00 AM

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Smokes tobacco daily (finding) (SNOMED CT#449868002)

Entry 30 - fullUrl = http://example.org/fhir/Observation/us-core-procedure-mammogram-jenny-m

Resource Procedure:

Generated Narrative: Procedure

Resource Procedure "us-core-procedure-mammogram-jenny-m"

Profile: US Core Procedure Profile

status: COMPLETED

code: Mammography (procedure) (SNOMED CT#71651007)

subject: See above (Patient/cancer-patient-jenny-m)

Performers

-Actor
*Practitioner/us-core-practitioner-jane-radiotech " RADIOLOGIST"

Entry 31 - fullUrl = http://example.org/fhir/FamilyMemberHistory/family-member-history-aunt-jenny-m

Resource FamilyMemberHistory:

Generated Narrative: FamilyMemberHistory

Resource FamilyMemberHistory "family-member-history-aunt-jenny-m"

status: COMPLETED

patient: See above (Patient/cancer-patient-jenny-m)

relationship: maternal aunt (RoleCode#MAUNT)

Conditions

-CodeOnset[x]
*Malignant tumor of ovary (disorder) (SNOMED CT#363443007)69 a (Details: UCUM code a = 'a')

Entry 32 - fullUrl = http://example.org/fhir/FamilyMemberHistory/family-member-history-uncle-jenny-m

Resource Procedure:

Generated Narrative: Procedure

Resource Procedure "us-core-procedure-mammogram-jenny-m"

Profile: US Core Procedure Profile

status: COMPLETED

code: Mammography (procedure) (SNOMED CT#71651007)

subject: See above (Patient/cancer-patient-jenny-m)

Performers

-Actor
*Practitioner/us-core-practitioner-jane-radiotech " RADIOLOGIST"

Entry 33 - fullUrl = http://example.org/fhir/DiagnosticReport/us-core-diagnosticreport-lab-jenny-m

Resource DiagnosticReport:

Pathology report final diagnosis Narrative (Laboratory)

SubjectJenny M female, DoB: 1965-01-01 ( Medical Record Number: MRN1234 (use: USUAL))
When For2018-04-01 00:00:00+0000
Reported2018-04-05 00:00:00+0000

Report Details

CodeValueWhen For
Status of invasion by tumorNegative (qualifier value)2018-04-01 00:00:00+0000
Margin involvement in Breast tumorUninvolved by invasive carcinoma2018-04-01 00:00:00+0000
Sentinel lymph nodes with metastasis [#] in Cancer specimen2018-04-01 00:00:00+0000
Size Tumor2018-04-01 00:00:00+0000
DCIS intraductal extension in Breast cancer specimen Qualitative by Light microscopyDCIS present with extensive intraductal component (EIC)2018-04-01 00:00:00+0000
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 22018-04-01 00:00:00+0000

Entry 34 - fullUrl = http://example.org/fhir/Observation/observation-smoking-pack-years-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "observation-smoking-pack-years-jenny-m"

status: FINAL

category: Social History (Observation Category Codes#social-history)

code: Cigarette pack-years (observable entity) (SNOMED CT#401201003)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-03-16

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: 20 Pack-Years (Details: UCUM code 1 = '1')

Entry 35 - fullUrl = http://example.org/fhir/Observation/us-core-observation-lab-tumor-invasion-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-observation-lab-tumor-invasion-jenny-m"

Profile: US Core Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Status of invasion by tumor (SNOMED CT#370052007)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-01 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Negative (qualifier value) (SNOMED CT#260385009)

specimen: Specimen/tumor-specimen-left-breast-jenny-m

Entry 36 - fullUrl = http://example.org/fhir/Observation/us-core-observation-lab-tumor-margins-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-observation-lab-tumor-margins-jenny-m"

Profile: US Core Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Margin involvement in Breast tumor (LOINC#44669-0)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-01 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: Uninvolved by invasive carcinoma (LOINC#LA27151-2)

specimen: Specimen/tumor-specimen-left-breast-jenny-m

Entry 37 - fullUrl = http://example.org/fhir/Observation/us-core-observation-lab-sentinel-nodes-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-observation-lab-sentinel-nodes-jenny-m"

Profile: US Core Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Sentinel lymph nodes with metastasis [#] in Cancer specimen (LOINC#92832-5)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-01 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

specimen: Specimen/tumor-specimen-left-breast-jenny-m

Components

-CodeValue[x]
*Lymph nodes examined [#] in Cancer specimen by Light microscopy (LOINC#92833-3)3 Count (Details: UCUM code 1 = '1')

Entry 38 - fullUrl = http://example.org/fhir/Observation/us-core-observation-lab-tumor-dcis-jenny-m

Resource Observation:

Generated Narrative: Observation

Resource Observation "us-core-observation-lab-tumor-dcis-jenny-m"

Profile: US Core Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: DCIS intraductal extension in Breast cancer specimen Qualitative by Light microscopy (LOINC#85336-6)

subject: See above (Patient/cancer-patient-jenny-m)

effective: 2018-04-01 00:00:00+0000

performer: See above (Practitioner/us-core-practitioner-owen-oncologist)

value: DCIS present with extensive intraductal component (EIC) (LOINC#LA27261-9)

specimen: Specimen/tumor-specimen-left-breast-jenny-m

Entry 39 - fullUrl = http://example.org/fhir/Practitioner/us-core-practitioner-owen-oncologist

Resource Practitioner:

Generated Narrative: Practitioner

Resource Practitioner "us-core-practitioner-owen-oncologist"

Profile: US Core Practitioner Profile

identifier: id: 9988776655

name: Owen Oncologist

gender: MALE

address: 123 Corporate Drive Anytown MA 12345 US (WORK)

Qualifications

-Code
*Doctor of Medicine (degreeLicenseCertificate[2.7]#MD)

Entry 40 - fullUrl = http://example.org/fhir/Practitioner/us-core-practitioner-peter-pathologist

Resource Practitioner:

Generated Narrative: Practitioner

Resource Practitioner "us-core-practitioner-peter-pathologist"

Profile: US Core Practitioner Profile

identifier: id: 1122334455

name: Peter Pathologist

gender: FEMALE

address: 123 Corporate Drive Anytown MA 12345 US (WORK)

Qualifications

-Code
*Doctor of Medicine (degreeLicenseCertificate[2.7]#MD)