醫療影像及報告實作指引
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{
"resourceType" : "DiagnosticReport",
"id" : "NASHDiagnosticReport",
"meta" : {
"profile" : [
🔗 "https://hapi.fhir.tw/fhir/StructureDefinition/NASH-DiagnosticReport"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport NASHDiagnosticReport</b></p><a name=\"NASHDiagnosticReport\"> </a><a name=\"hcNASHDiagnosticReport\"> </a><a name=\"hcNASHDiagnosticReport-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-NASHGrossFinding.html\"><span title=\"Codes:{http://snomed.info/sct 371475003}\">Specimen size</span></a></td><td>1.5 x 0.1 x 0.1 cm</td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHNecroinflammatoryGrading.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 1}\">Necroinflammatory grading</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Necroinflammatory-Grading 1}\">Grade 1 (mild)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHFibrosisStaging.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 2}\">Fibrosis staging</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Fibrosis-Staging 2}\">Stage 2</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHBruntScoringSystem.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 3}\">Brunt Scoring System</span></a></td><td/><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHSteatosis.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 4}\">Steatosis</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Steatosis 2}\">20-30%</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHLobularInflammation.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 5}\">Lobular inflammation</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Lobular-Inflammation 2}\">2-4 foci</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHBallooning.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 6}\">Ballooning</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Ballooning 1}\">few</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHFibrosisStage.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 7}\">Fibrosis stage</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Fibrosis-Stage 2}\">Zone 3 perisinusoidal AND periportal fibrosis</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHCRNScoringSystem.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 8}\">CRN Scoring System</span></a></td><td/><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHPeriportalBridgingNecrosis.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 10}\">Periportal/bridging necrosis</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Periportal-Bridging-Necrosis 1}\">mild piecemeal necrosis</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHIntralobularDegenerationNecrosis.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 11}\">Intralobular degeneration/necrosis</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Intralobular-Degeneration-Necrosis 1}\">mild (acidophilic bodies, ballooning degeneration and/or scattered foci of hepatocellular necrosis in <1/3 of lobules or nodules)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHPortalInflammation.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 12}\">Portal inflammation</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Portal-Inflammation 1}\">mild (sprinkling of inflammatory cells in <1/3 of portal tracts)</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHFibrosis.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 13}\">Fibrosis</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Fibrosis 1}\">fibrous portal expansion</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHKnodellScoreSystem.html\"><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Variables 9}\">Knodell Histological Activity Index</span></a></td><td><span title=\"Codes:{https://hapi.fhir.tw/fhir/CodeSystem/NASH-Knodell 4}\">輕度病變，可能有輕微的活動性炎症、輕度纖維化和/或輕度細胞增生</span></td><td>Final</td><td>2021-06-21</td></tr><tr><td><a href=\"Observation-NASHMetavirFibrosisScore.html\"><span title=\"Codes:{http://loinc.org 48794-2}\">Fibrosis stage</span></a></td><td><span title=\"Codes:{http://loinc.org LA9635-9}\">No Fibrosis</span></td><td>Final</td><td>2021-06-21</td></tr></table></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/",
"value" : "123456"
}
],
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "LP7839-6",
"display" : "Pathology"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "22637-3",
"display" : "Pathology report final diagnosis Narrative"
}
]
},
"subject" : {
🔗 "reference" : "Patient/TWCorePatient"
},
"encounter" : {
🔗 "reference" : "Encounter/TWCoreEncounter"
},
"issued" : "2021-06-23T14:35:32.631Z",
"performer" : [
{
🔗 "reference" : "Practitioner/TWCorePractitioner"
}
],
"resultsInterpreter" : [
{
🔗 "reference" : "Practitioner/TWCorePractitioner"
}
],
"specimen" : [
{
🔗 "reference" : "Specimen/TWCoreSpecimen"
}
],
"result" : [
{
🔗 "reference" : "Observation/NASHGrossFinding"
},
{
🔗 "reference" : "Observation/NASHNecroinflammatoryGrading"
},
{
🔗 "reference" : "Observation/NASHFibrosisStaging"
},
{
🔗 "reference" : "Observation/NASHBruntScoringSystem"
},
{
🔗 "reference" : "Observation/NASHSteatosis"
},
{
🔗 "reference" : "Observation/NASHLobularInflammation"
},
{
🔗 "reference" : "Observation/NASHBallooning"
},
{
🔗 "reference" : "Observation/NASHFibrosisStage"
},
{
🔗 "reference" : "Observation/NASHCRNScoringSystem"
},
{
🔗 "reference" : "Observation/NASHPeriportalBridgingNecrosis"
},
{
🔗 "reference" : "Observation/NASHIntralobularDegenerationNecrosis"
},
{
🔗 "reference" : "Observation/NASHPortalInflammation"
},
{
🔗 "reference" : "Observation/NASHFibrosis"
},
{
🔗 "reference" : "Observation/NASHKnodellScoreSystem"
},
{
🔗 "reference" : "Observation/NASHMetavirFibrosisScore"
}
],
"imagingStudy" : [
{
🔗 "reference" : "ImagingStudy/ImagingStudyBase"
}
]
}