R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Diagnosticreport-example-papsmear

Orders and Observations Work Group

Maturity Level: N/A

Ballot Status: Informative

Compartments: Device, Encounter, Patient, Practitioner

This is the narrative for the resource. See also the XML or JSON format. This example conforms to the profile DiagnosticReport.

Acme Anatomic Pathology Services
2216 Santa Monica Blvd, Suite 114
Santa Monica, CA 90404
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GYN CYTOLOGY (PAP SMEAR) REPORT
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Patient: Everywoman, Eve Report Date: 2/14/2013
DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567
Patient Address: 2222 Home Street
Huntington Park
CA 90255
Order: ORD40
Physician: Careful, Adam 5742200012 (NPI)
SpecimenID: GHSID40
Collected Date: 2/11/2013
Received Date: 2/12/2013
LMP: 1/28/2013
Specimen Source: Cervical Cytology (ThinPrep)
Previously abnormal Pap? Unknown

Specimen Adequacy: Satisfactory
Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells
of undetermined significance
Hormonal Evaluations: not possible, due to presence of atypical cells
Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated
Comments: Abnormal report reviewed by pathologist for confirmation

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.