醫療影像及報告實作指引
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醫療影像及報告實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:DiagnosticReport ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "DiagnosticReportLC"] ; #
fhir:meta [
( fhir:profile [
fhir:v "https://hapi.fhir.tw/fhir/StructureDefinition/DiagnosticReport-LC"^^xsd:anyURI ;
fhir:link <https://hapi.fhir.tw/fhir/StructureDefinition/DiagnosticReport-LC> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport DiagnosticReportLC</b></p><a name=\"DiagnosticReportLC\"> </a><a name=\"hcDiagnosticReportLC\"> </a><a name=\"hcDiagnosticReportLC-en-US\"> </a><h2><span title=\"Codes:{http://loinc.org 22637-3}\">Pathology report final diagnosis Narrative</span> (<span title=\"Codes:{http://loinc.org LP7839-6}\">Pathology</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>No display for Patient </td></tr><tr><td>Reported</td><td>2021-06-23 14:35:32+0000</td></tr><tr><td>Performer</td><td> <a href=\"Practitioner-TWCorePractitioner.html\">Practitioner 大吉 連 (official)</a></td></tr><tr><td>Identifier</td><td> <code>https://www.vghtpe.gov.tw/</code>/123456</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>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href=\"Observation-GrossFinding.html\"><span title=\"Codes:{http://loinc.org 22634-0}\">Pathology report gross observation Narrative</span></a></td><td>The specimen received in formalin has 3 parts. Part (A) consists of a piece of lung, labeled RLL segment and measures 6.5 x 3.3 x1.8 cm. A gray white firm tumor, 1.2 x 0.5 x 0.5 cm, is noted 0.8 cm from the bronchial cut end, 0.1 cm from visceral pleura.Part (B) consists of groups of lymph nodes labeled as above.Part (C) is a piece of lung labeled 'RLL margin', measuring 3.8x 1.8 x 1 cm. Representative parts are taken for sections in 5 blocks. (A:bronchial and vascular cut end, B:stapled margin,C:tumor, D:specimen labeled 'RLL margin', E:interlobar LNs)(WKW)</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Histologictype.html\"><span title=\"Codes:{http://loinc.org 33731-1}\">Histology type in Cancer specimen Narrative</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/ICD-O-3-Morphology 81402}, {https://hapi.fhir.tw/fhir/CodeSystem/ICD-O-3-Morphology 85503}\">adenocarcinoma,acinar predominant</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Histologicpattern.html\"><span title=\"Codes:{http://snomed.info/sct 255711007}\">Pattern (attribute)</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-Histologic-pattern acinar}, {https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-Histologic-pattern lepidic}\">acinar(90%),lepidic(10%)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Celltype.html\"><span title=\"Codes:{http://loinc.org 32760-1}\">Cell type in Specimen</span></a></td><td>non-mucinous tumor cells</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Resectionmargin.html\"><span title=\"Codes:{http://loinc.org 21939-4}\">Surgical margins cancer involvement</span></a></td><td>free of tumor involvement</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Nontumorousparenchyma.html\"><span title=\"Codes:{http://snomed.info/sct 113255004}\">Structure of parenchyma of lung (body structure)</span></a></td><td>congestion</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Totaltumorsize.html\"><span title=\"Codes:{http://loinc.org 21889-1}\">Size Tumor</span></a></td><td>0.6x0.4cm</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Sizeofinvasivefocus.html\"><span title=\"Codes:{http://loinc.org 33759-2}\">Deepest extent of invasion [Type] in Specimen</span></a></td><td>0.6 cm<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codecm = 'cm')</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Angiolymphaticinvasion.html\"><span title=\"Codes:{http://loinc.org 59544-7}\">Lymph-vascular invasion Cancer specimen</span></a></td><td><span title=\"Codes:{http://loinc.org LA9634-2}\">absent</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Perineuralinvasion.html\"><span title=\"Codes:{http://loinc.org 92837-4}\">Perineural invasion [Presence] in Cancer specimen</span></a></td><td><span title=\"Codes:{http://loinc.org LA9634-2}\">absent</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Pleuralinvasion.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-MicroscopicFinding Pleural-invasion}\">Pleural invasion</span></a></td><td><span title=\"Codes:{http://loinc.org LA9634-2}, {https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-Pleural-Invasion PL0}\">absent(PL0)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-SpreadThroughAirSpaces.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-MicroscopicFinding STAS}\">Spread Through Air Spaces(STAS)</span></a></td><td><span title=\"Codes:{http://loinc.org LA9634-2}\">absent</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Tumornecrosis.html\"><span title=\"Codes:{http://snomed.info/sct 34823008}\">Tumor necrosis (morphologic abnormality)</span></a></td><td><span title=\"Codes:{http://loinc.org LA9634-2}\">absent</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Tcategory.html\"><span title=\"Codes:{http://loinc.org 21899-0}\">Primary tumor.pathology Cancer</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-pT T1a}\">tumor <=1 cm or less in greatest dimension(pT1a)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Lymphnodes.html\"><span title=\"Codes:{http://loinc.org 21900-6}\">Regional lymph nodes.pathology [Class] Cancer</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-pN N0}\">all without metastatic tumor(pN0)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Metastasis.html\"><span title=\"Codes:{http://loinc.org 21901-4}\">Distant metastases.pathology [Class] Cancer</span></a></td><td><span style=\"color: maroon\" title=\"Error\">Error: <b><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/data-absent-reason unknown}\">unknown</span></b></span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Pathologicalstaging.html\"><span title=\"Codes:{http://loinc.org 21914-7}\">Stage group.other Cancer</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-pTNM IA1}\">pT1aN0</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Tumorgrading.html\"><span title=\"Codes:{http://snomed.info/sct 397005006}\">World Health Organization tumor classification (observable entity)</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-Grading G2}\">Grade group 2 (microscopic measurement)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-Ancillarystudies.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NSCLC-MicroscopicFinding Ancillary}\">Ancillary studies</span></a></td><td>Tumor cell positive for TTF-1 and negative for p40;Multinucleate giant cell negative for CK</td><td>Final</td><td>2021-06-21</td></tr></table><p>Adenocarcinoma, acinar predominant, pT1aN0</p></div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "https://www.vghtpe.gov.tw/"^^xsd:anyURI ] ;
fhir:value [ fhir:v "123456" ]
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fhir:status [ fhir:v "final"] ; #
fhir:category ( [
( fhir:coding [
a loinc:LP7839-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LP7839-6" ] ;
fhir:display [ fhir:v "Pathology" ] ] )
] ) ; #
fhir:code [
( fhir:coding [
a loinc:22637-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "22637-3" ] ;
fhir:display [ fhir:v "Pathology report final diagnosis Narrative" ] ] )
] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/TWCorePatient" ]
] ; #
fhir:encounter [
fhir:reference [ fhir:v "Encounter/TWCoreEncounter" ]
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fhir:issued [ fhir:v "2021-06-23T14:35:32.631Z"^^xsd:dateTime] ; #
fhir:performer ( [
fhir:reference [ fhir:v "Practitioner/TWCorePractitioner" ]
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fhir:resultsInterpreter ( [
fhir:reference [ fhir:v "Practitioner/TWCorePractitioner" ]
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fhir:specimen ( [
fhir:reference [ fhir:v "Specimen/TWCoreSpecimen" ]
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fhir:result ( [
fhir:reference [ fhir:v "Observation/GrossFinding" ]
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fhir:reference [ fhir:v "Observation/Histologictype" ]
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fhir:reference [ fhir:v "Observation/Histologicpattern" ]
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fhir:reference [ fhir:v "Observation/Celltype" ]
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fhir:reference [ fhir:v "Observation/Resectionmargin" ]
] [
fhir:reference [ fhir:v "Observation/Nontumorousparenchyma" ]
] [
fhir:reference [ fhir:v "Observation/Totaltumorsize" ]
] [
fhir:reference [ fhir:v "Observation/Sizeofinvasivefocus" ]
] [
fhir:reference [ fhir:v "Observation/Angiolymphaticinvasion" ]
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fhir:reference [ fhir:v "Observation/Perineuralinvasion" ]
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fhir:reference [ fhir:v "Observation/Pleuralinvasion" ]
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fhir:reference [ fhir:v "Observation/SpreadThroughAirSpaces" ]
] [
fhir:reference [ fhir:v "Observation/Tumornecrosis" ]
] [
fhir:reference [ fhir:v "Observation/Tcategory" ]
] [
fhir:reference [ fhir:v "Observation/Lymphnodes" ]
] [
fhir:reference [ fhir:v "Observation/Metastasis" ]
] [
fhir:reference [ fhir:v "Observation/Pathologicalstaging" ]
] [
fhir:reference [ fhir:v "Observation/Tumorgrading" ]
] [
fhir:reference [ fhir:v "Observation/Ancillarystudies" ]
] ) ; #
fhir:imagingStudy ( [
fhir:reference [ fhir:v "ImagingStudy/ImagingStudyBase" ]
] ) ; #
fhir:conclusion [ fhir:v "Adenocarcinoma, acinar predominant, pT1aN0"] . #
IG © 2022+ CYLAB. Package fhir.PATHIMG#0.1.0 based on FHIR 4.0.1. Generated 2024-07-29
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