This page is part of the FHIR Specification (v1.2.0: STU 3 Draft). The current version which supercedes this version is 4.0.1. For a full list of available versions, see the Directory of published versions
Logical Model Colorectal
{ "resourceType": "StructureDefinition", "id": "Colorectal", "text": { "status": "generated", "div": "<div>to do</div>" }, "url": "http://hl7.org/fhir/StructureDefinition/Colorectal", "name": "Colorectal", "display": "nehta-colorectal", "status": "draft", "publisher": "Health Level Seven International fhir", "contact": [ { "telecom": [ { "system": "other", "value": "http://hl7.org/fhir" } ] } ], "date": "2015-11-25T21:05:34+11:00", "description": "Logical Model: Colorectal cancer.", "fhirVersion": "1.0.2", "mapping": [ { "identity": "logical", "uri": "http://hl7.org/fhir/logical", "name": "Logical Mapping" }, { "identity": "cap", "uri": "http://cap.org/ecc", "name": "CAP Code" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM" }, { "identity": "sct", "uri": "http://snomed.info", "name": "SNOMED-CT" }, { "identity": "loinc", "uri": "http://loinc.org", "name": "LOINC" } ], "kind": "logical", "abstract": false, "snapshot": { "element": [ { "path": "Colorectal", "short": "Colorectal", "definition": "Colorectal cancer.", "min": 0, "max": "*", "mapping": [ { "identity": "logical", "map": "dr := DiagnosticReport" }, { "identity": "cap", "map": "28282.1000043" } ] }, { "path": "Colorectal.subject", "short": "The subject of the report, usually, but not always, the patient", "definition": "The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.", "alias": [ "Patient" ], "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Group" ] } ], "isSummary": true, "mapping": [ { "identity": "logical", "map": "dr.subject" }, { "identity": "v2", "map": "PID-3-Patient ID List (no V2 mapping for Group or Device)" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "sct", "map": "116154003" } ] }, { "path": "Colorectal.requester", "short": "Who ordered the test", "definition": "The practitioner that holds legal responsibility for ordering the investigation.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ] } ], "isSummary": true, "mapping": [ { "identity": "logical", "map": "!req := dr.request->DiagnosticOrder; req[orderer := $value]" }, { "identity": "loinc", "map": "22027-7" }, { "identity": "rim", "map": "participation[typeCode=AUT].role" }, { "identity": "sct", "map": "223366009" } ] }, { "path": "Colorectal.performer", "short": "Responsible Diagnostic Service", "definition": "The diagnostic service that is responsible for issuing the report.", "comments": "This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.", "requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.", "alias": [ "Laboratory", "Service", "Practitioner", "Department", "Company" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "isSummary": true, "mapping": [ { "identity": "logical", "map": "dr[performer := $value]" }, { "identity": "v2", "map": "PRT-8-Participation Organization (where this PRT-4-Participation = \"PO\")" }, { "identity": "rim", "map": "participation[typeCode=AUT].role[classCode=ASSIGN].scoper" }, { "identity": "sct", "map": "420158005" } ] }, { "path": "Colorectal.preAnalytic", "short": "Pre Analytic", "definition": "Pre Analytic component - information collection prior to specimen receipt at laboratory.", "comments": "This is just a group/section header and is not a result field.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "constraint": [ { "key": "inv-01", "severity": "error", "human": "If there is a perforation, the perforation type must be indicated.", "xpath": "not(f:perforation/@value = 'present') or exists(f:natureOfPerforation)" } ], "mapping": [ { "identity": "logical", "map": "req := dr.request->DiagnosticOrder; req[orderer := $value]" }, { "identity": "cap", "map": "28592.1000043" }, { "identity": "loinc", "map": "70949-3" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "A: Specimen labelled : right hemicolectomy\nB: Mesentric lymph node" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.clinicalInformation", "short": "Clinical information", "definition": "Clinical information provided on request form.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "req.reason[text := $value]" }, { "identity": "cap", "map": "28593.1000043" }, { "identity": "loinc", "map": "55752-0" } ] }, { "path": "Colorectal.preAnalytic.operatingSurgeonDetails", "short": "Operating surgeon details", "definition": "The operating surgeon name and contact details.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ] } ], "isSummary": true, "mapping": [ { "identity": "logical", "map": "sp := dr.specimen->Specimen; sp.collection[collector := $value]" }, { "identity": "loinc", "map": "22027-7" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.perforation", "short": "Perforation", "definition": "Presence or absence of a perforation.", "requirements": "If present, record the nature of perforation.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-01" ], "binding": { "strength": "required", "description": "A code that indicates whether perforation is present", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-ns" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28289.1000043" }, { "identity": "sct", "map": "36191001" } ] }, { "path": "Colorectal.preAnalytic.natureOfPerforation", "short": "Nature of perforation", "definition": "The type of perforation.", "min": 0, "max": "*", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the type of perforation", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-perforation-type" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28296.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.clinicalObstruction", "short": "Clinical obstruction", "definition": "Whether a clinical obstruction is present or absent.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates whether a clinical obstruction is present", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-ns" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28292.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Rectum" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Lower rectum" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.tumourLocation", "short": "Tumour location", "definition": "Anatomical location of the tumour from a given list.", "min": 0, "max": "*", "type": [ { "code": "code" } ], "condition": [ "inv-02" ], "constraint": [ { "key": "inv-02", "severity": "error", "human": "If the tumour location is rectum, then the distance from the anal verge must be recorded.", "xpath": "not(@value = 'Rectum') or exists(f:distanceAnalVerge)" } ], "binding": { "strength": "required", "description": "A code that indicates the antomical location of the tumour from a given list", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-tumour-location" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28307.1000043" }, { "identity": "loinc", "map": "33725-3" }, { "identity": "sct", "map": "371480007" } ] }, { "path": "Colorectal.preAnalytic.synchronousTumours", "short": "Synchronous tumours - other site", "definition": "For synchronous tumours indicate each other site.", "comments": "Note\n: Synchronous tumours should be reported separately – this serves only to identify the presence of other synchronous tumours for which separate reports will be submitted.", "requirements": "Conditional on rectum being selected.\nMeasured in cm for RCPA requirements.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28346.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueQuantity": { "value": 6, "unit": "cm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.distanceAnalVerge", "short": "Distance from anal verge", "definition": "Quantitative measurement of distance from anal verge.", "comments": "Conditional on rectum being selected\nNote : Measured in cm by longstanding surgical convention.", "requirements": "Conditional on rectum being selected.\nMeasured in cm for RCPA requirements.", "min": 0, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28335.1000043" }, { "identity": "loinc", "map": "33748-5" }, { "identity": "sct", "map": "371490004" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Anterior resection" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Right hemicolectomy" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Anterior resection" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.typeOfOperation", "short": "*", "definition": "The type of operation selected from a list.", "requirements": "Single selection value list.\nIf other procedure(s) is selected, record type of procedure.\nIf anterior resection is selected, record anterior resection type.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-03", "inv-04" ], "constraint": [ { "key": "inv-03", "severity": "error", "human": "If other procedure(s) is selected, then record the type of procedure.", "xpath": "not(@value = 'Other procedure(s)') or exists(f:typeOfProcedure)" }, { "key": "inv-04", "severity": "error", "human": "If anterior resection is selected, record anterior resection type.", "xpath": "not(@value = 'Anterior resection') or exists(f:anteriorResectionType)" } ], "binding": { "strength": "required", "description": "A code that indicates the type of operation", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-operation-type" } }, "mapping": [ { "identity": "logical", "map": "too := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "27919.1000043" }, { "identity": "loinc", "map": "29306-8" } ] }, { "path": "Colorectal.preAnalytic.typeOfProcedure", "short": "Procedure type", "definition": "Type of procedure.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "too.text" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Ultralow" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.anteriorResectionType", "short": "Anterior resection type", "definition": "The type of anterior resection.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that idicates the type of anterior resection", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-hi-lo-ultralo" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28278.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Yes" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.preoperativeRadiotherapy", "short": "Pre-operative radiotherapy", "definition": "An indication of pre-operative radiotherapy.", "requirements": "Single selection value list.\nIf yes, record type of course.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-05" ], "constraint": [ { "key": "inv-05", "severity": "error", "human": "If pre-operative radiotherapy is done, then the type of course is to be recorded.", "xpath": "not(@value = 'Yes') or exists(f:typeOfCourse)" } ], "binding": { "strength": "required", "description": "A code that indicates whether pre-operative radiotherapy was used", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-yes-no-ns" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28283.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Short duration" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.typeOfCourse", "short": "Type of course", "definition": "The type of course of pre-operative radiotherapy.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the type of course of pre-operative radiotherapy", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-course-type" } }, "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28286.100004299999" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "None noted" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.surgeonsOpinion", "short": "Surgeons opinion of residual cancer", "definition": "Surgeons opinion on the existence of local residual cancer postsurgery.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28295.1000043" } ] }, { "path": "Colorectal.preAnalytic.adjacentOrgans", "short": "Adjacent organ involvement", "definition": "Involvement of adjacent organs.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28336.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "New primary" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.newPrimaryOrRecurrence", "short": "New primary cancer or recurrence", "definition": "An indication of whether a new primary cancer or a recurrence.", "comments": "? If need to make an invariant due to the conditional statement.", "requirements": "Single selection value list.\nIf regional (local) recurrence or distant metastasis describe.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-06" ], "constraint": [ { "key": "inv-06", "severity": "error", "human": "If regional (local) recurrence or distant metastasis describe.", "xpath": "not((@value = 'Regional (local) recurrence') or (@value = 'Distant metastases')) or exists(f:describe)" } ], "binding": { "strength": "required", "description": "A code that indicates whether a new primary cancer or an recurrence", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-cancer-primary-or-recurrence" } }, "mapping": [ { "identity": "logical", "map": "pno := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28337.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "No metastatic lesions" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.RecurrenceDescription", "short": "Describe", "definition": "Description of regional (local) recurrence or distant metastases.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "pno.component[code := %map-codes; value[x] := $value]" } ] }, { "path": "Colorectal.preAnalytic.pathologyAccessionNumber", "short": "Pathology number", "definition": "Pathology accession number.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "dr[identifier := $value]" }, { "identity": "cap", "map": "28300.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Tissue banking: No\nSpecimen images: Yes" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.preAnalytic.otherRelevantDetails", "short": "Other details", "definition": "Other relevant details.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "req.note[text := $value]" }, { "identity": "cap", "map": "28301.1000043" } ] }, { "path": "Colorectal.macro", "short": "Macroscopy", "definition": "Macroscopic findings.", "comments": "This is just a group/section header and is not a result field.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "constraint": [ { "key": "inv-15", "severity": "error", "human": "If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded.", "xpath": "not(lymphNodes/@value = 'Received') or exists(f:.lymphNodeInvolvement)" }, { "key": "inv-09", "severity": "error", "human": "If lymph nodes are received, record the number of nodes", "xpath": "not(f:lymphNodes/@value = 'Received') or exists(f:noLymphNodesPerCassette)" } ], "mapping": [ { "identity": "logical", "map": "macro := dr.result->Observation[code := %map-codes]" }, { "identity": "cap", "map": "27906.1000043" }, { "identity": "loinc", "map": "70949-3" }, { "identity": "sct", "map": "250429001" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueQuantity": { "value": 130, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 240, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueQuantity": { "value": 85, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.specimenLength", "short": "Specimen length", "definition": "The length of the specimen.", "comments": "Query if measurements are in mm is international ie USA and query if this comment needs to be refined to AUS?\nDitto for subsequent metric measurements.", "requirements": "measurement in mm.", "min": 1, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "sp1 := dr.specimen->Specimen; sp1.collection[quantity := $value]" }, { "identity": "cap", "map": "28342.1000043" }, { "identity": "loinc", "map": "33723-8" }, { "identity": "sct", "map": "384606002" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Rectum" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Rectum" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Caecum" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.tumourSite", "short": "Tumour site", "definition": "The site of the tumour.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-07", "inv-08", "inv-13" ], "constraint": [ { "key": "inv-13", "severity": "error", "human": "If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded.", "xpath": "not(f:Colorectal.preAnalytic.tumourLocation/@value = 'Rectum') or exists(f:Colorectal.micro.nonperitonealisedCircumMargin)" }, { "key": "inv-08", "severity": "error", "human": "If tumour site is rectum, the intactness of mesorectum is to be recorded.", "xpath": "not(@value = 'Rectum') or exists(f:intactnessOfMesorectum)" }, { "key": "inv-07", "severity": "error", "human": "If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded.", "xpath": "not(@value = 'Rectum') or exists(f:relToAntPeritonealReflection)" } ], "binding": { "strength": "required", "description": "A code that indicates the site of the tumour", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-tumour-location" } }, "mapping": [ { "identity": "logical", "map": "sp2 := dr.specimen->Specimen; sp2.collection[bodySite := $value]" }, { "identity": "cap", "map": "27931.1000043" }, { "identity": "loinc", "map": "33725-3" }, { "identity": "sct", "map": "371480007" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueQuantity": { "value": 50, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 45, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueQuantity": { "value": 90, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.maxTumourDiameter", "short": "Max. tumour diameter", "definition": "Maximum tumour diameter.", "requirements": "measurement in mm.", "min": 1, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28360.1000043" }, { "identity": "loinc", "map": "21889-1" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueQuantity": { "value": 20, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 6, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueQuantity": { "value": 70, "unit": "mm (Proximal)" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.distanceNearerProxOrDistal", "short": "Dist. of tumour to the nearer proximal or distal \"cut end\"", "definition": "Distance of tumour to the nearer proximal or distal \"cut end\".", "requirements": "measurement in mm.", "min": 1, "max": "*", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28359.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueQuantity": { "value": 15, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 10, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueQuantity": { "value": 15, "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.distNonperitonCircumMargin", "short": "Dist. of tumour to the nonperitonealised circumferential margin", "definition": "Distance of tumour to the nonperitonealised circumferential margin.", "requirements": "measurement in mm.", "min": 1, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28358.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.tumourPerforation", "short": "Tumour perforation", "definition": "The presence or absence of tumour perforation.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the presence or absence of a tumour perforation", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "27963.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Astride" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Astride" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.relToAntPeritonealReflection", "short": "Relationship to anterior peritoneal reflection", "definition": "Site of tumour in relation to the anterior level of the peritoneal reflection.", "requirements": "Single selection value list.\nConditional on rectum being selected in Tumour Site.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the site of tumour in relation to the anterior level of the peritoneal reflection", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-rel-anterior-peritoneal-reflection" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28362.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Complete (grade 3)" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Complete (grade 3)" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.intactnessOfMesorectum", "short": "Intactness of mesorectum", "definition": "For rectal resections the intactness of the mesorectum must be recorded.", "requirements": "Single selection value list.\nConditional on rectum being selected in Tumour Site.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the intactness of the mesorectum", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-intactness-of-mesorectum" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "27967.1000043" }, { "identity": "loinc", "map": "33730-3" }, { "identity": "sct", "map": "408655002" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Tumour has formed nodule(s) discrete from the tumour mass along the serosal surface. An 8mm submucosal nodule, 20mm from the distal margin is noted." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Tumour invades to the peritoneal surface" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.peritoneum", "short": "Peritoneum", "definition": "Any involvement of the peritoneum should be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the tumour invovlement in the peritoneum", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-peritoneum-invasion" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28369.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Received" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Received" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Received" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.lymphNodes", "short": "Lymph nodes", "definition": "If lymph nodes are received, then they should be recorded.", "requirements": "Conditional:\nIf received, record the number of nodes.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-09", "inv-15" ], "binding": { "strength": "required", "description": "A code that indicates if lymph nodes were received", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-received-notreceived" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28372.1000043" }, { "identity": "loinc", "map": "?? \n44621-1" }, { "identity": "sct", "map": "364108009" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "3 in cassette 1 \n4 in cassette 2\n7 in cassette 3" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "1 in cassette 1\n4 in cassette 2\n3 in cassette 3" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "21 in total.\nA11 – 1 node, serially sliced\n A12 – 1 node, serially sliced\n A13 – 1 node, serially sliced\n A14 – 1 node, serially sliced\n A15 – 1 node, apical node, bisected and entirely submitted.\nA16 – 3 nodes\n A17 – 3 nodes\n A18 – 3 nodes\n A19 – 6 nodes, 1 bisected\n B - Mesentric lymph node Bisected and entirely submitted in 1 block" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.noLymphNodesPerCassette", "short": "Number of lymph nodes in each cassette", "definition": "The number of lymph nodes placed in each cassette should be recorded.", "comments": "The RCPA require the following be recorded:\n\"Numeric: ___ in cassette: ___\"\nQuery how to record this?", "min": 0, "max": "*", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28387.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.polyps", "short": "Polyps", "definition": "The presence or absence of polyps should be recorded.", "requirements": "Conditional:\nIf present, provide a polyp summary.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-10" ], "constraint": [ { "key": "inv-10", "severity": "error", "human": "If polyps are present, provide a polyp summary.", "xpath": "not(f@value = 'Present') or exists(f:polypSummary)" } ], "binding": { "strength": "required", "description": "A code that indicates the presence or absence of polyp(s)", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-na" } }, "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28376.1000043" }, { "identity": "loinc", "map": "?? 33745-1" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Two 5mm polyps are noted." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.polypSummary", "short": "The number, diameter and gross configuration of polyps should be summarised", "definition": "The polyp summary should include the numbers, diameter range and gross appearance.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28379.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Tumour appears ulcerated and scarred. Overlying serosa appears normal. Extramuscular spread to 15mm" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Tumour appears plaquelike, remaining mucosa appears normal." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "A segment of large bowel 175mm in length with an internal diameter of up to 52mm. The bowel has been opened prior to receipt. The peritoneal reflection has not been included in the specimen. Arising at 45mm from the presumed distal margin, a raised ulcerated firm tan tumour is present measuring 55x32mm. On slicing the tumour measures up to 10mm in thickness and infiltrates into the mesocolic fat. On the antimesenteric border, the tumour abuts the serosal surface. Tumour perforation is not seen. No other lesions are identified within the mucosa elsewhere. Blocks 1, 2 - reps of tumour with mesocolic fat. Blocks 3,4,5 - tumour with peritoneal surface. Block 6 - distal resection margin. Block 7 - apical lymph node. Block 8 - one lymph node. Block 9 - four lymph nodes. Block 10 - five lymph nodes. PP. (TW.LD)" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.otherMacroComments", "short": "Other macroscopic comments", "definition": "A descriptive or narrative field should be provided to record any macroscopic information that is not recorded in the above standards and guidelines, and that would normally form part of the macroscopic description.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28380.1000043" }, { "identity": "sct", "map": "395526000" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Blocks 1 to 6: tumour. Block 7: distal margin. Blocks 8 & 9 : circumferential margin. Blocks 10 to 16: 14 lymph nodes (2 in each block)." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Blocks 1: shaved vascular margin, 2 to 4: tumour with greatest depth of invasion, radial inked red, distal inked blue. 5 – tumour with adjacent mucosa. 6-9 lymph nodes" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "A1-A2 - Omentum.\nA3 - Ileal margin with adjacent noninvolved ileum.\nA4 - Appendix with base painted.\nA5-A6 - Tumour at ileocaecal junction.\nA7-A8 - Representative sections of tumour.\nA9 - Tumour with nonperitonealised margin.\nA10 - Ascending colon and distal resection margin.\nLymph nodes as above" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.macro.natureAndSiteOfBlocks", "short": "Nature and site of blocks", "definition": "The nature and sites of all blocks must be recorded.", "min": 1, "max": "*", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28381.100004299999" } ] }, { "path": "Colorectal.micro", "short": "Microscopy", "definition": "Microscopy of the sample.", "comments": "This is just a group/section header and is not a result field.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "mapping": [ { "identity": "logical", "map": "micro := dr.result->Observation[code := %map-codes]" }, { "identity": "cap", "map": "27973.1000043" }, { "identity": "loinc", "map": "70949-3" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Adenocarcinoma" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Adenocarcinoma, NOS" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Adenocarcinoma" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Adenocarcinoma, with mucinous areas" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.tumourType", "short": "Tumour type", "definition": "A single selection value list from WHO Classification of Tumours.", "comments": "How to represent this result group which has heading and components cf the bindings file is a flat file??", "requirements": "Single selection value list from WHO Classification of Tumours. Pathology and Genetics of Tumours of the Digestive System (2010).", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code from the WHO Calssification that indicates the tumour type", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-tumour-type" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "27974.1000043" }, { "identity": "sct", "map": "371441004" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Low grade – well and moderately differentiated" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Low grade – well and moderately differentiated" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Low grade – well and moderately differentiated" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "High grade - poorly and undifferentiated" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.histologicalGrade", "short": "Histological grade", "definition": "The histological grading of the tumour must be recorded.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the histological grade of the tumour", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-histological-grade" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "27988.1000043" }, { "identity": "sct", "map": "371469007" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "pT3 Tumour invades through muscularis propria into pericolorectal tissues, specifically into perirectal fat" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "pT3 Tumour invades through muscularis propria into pericolorectal tissues.\n\n(For Grahame: The actual result value was:\nBeyond muscularis propria (pT3). Maximum distance of spread beyond muscularis propria: 5 mm.\nFYI- the second sentence was added to the Cooments, which Meagan was OK with." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "pT3 Tumour invades through muscularis propria into pericolorectal tissues" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.maxDegreeLocalInvasion", "short": "Maximum degree of local invasion into or through the bowel wall", "definition": "The maximum degree of local invasion into or through the bowel wall must be recorded.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the maximum degree of local invasion into or through the bowel wall", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-deg-inv-bowel-wall" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28534.1000043" }, { "identity": "loinc", "map": "33759-2" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Not involved" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Not invovled" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.proximalOrDistalResectionMargins", "short": "Involvement of the proximal or distal resection (cut-end) margins", "definition": "Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.", "requirements": "Single selection value list.\nIf involved is selected, record involved margin(s)\nIf not involved is selected, record microscopic clearance.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-11", "inv-12" ], "constraint": [ { "key": "inv-12", "severity": "error", "human": "If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance.", "xpath": "not(@value = 'Not involved') or exists(f:microClearance)" }, { "key": "inv-11", "severity": "error", "human": "If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s).", "xpath": "not(f@value = 'Involved') or exists(f:involvedMargins)" } ], "binding": { "strength": "required", "description": "A code that indicates involvement of the proximal or distal resection (cut-end) margins", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-involved-notinvolved" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28348.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Proximal;\nDistal" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.involvedMargins", "short": "Involved margin(s)", "definition": "Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.", "requirements": "Multi select value list (select all that apply).\nThis is a conditional field.", "min": 1, "max": "*", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the involvement at the margins", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-distal-proximal" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28351.1000043" }, { "identity": "sct", "map": "423105004" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 10, "comparator": ">", "unit": "mm (Proximal)" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueQuantity": { "value": 10, "comparator": ">", "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueQuantity": { "value": 10, "comparator": ">", "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.marginsMicroClearance", "short": "Microscopic Clearance", "definition": "If the margin is less than 10 mm, the clearance must be recorded.", "comments": "Query how to achieve this??", "requirements": "Numeric: ___mm (if the margin is less than 10 mm)\nOR Clearance is ≥10mm.", "min": 0, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28396.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Involved" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.nonperitonealisedCircumMargin", "short": "Status of the nonperitonealised circumferential margin (rectal tumours)", "definition": "The status of the nonperitonealised circumferential margin in rectal tumours must be recorded.", "requirements": "Single selection value list.\nConditional on rectum being selected in S2.02\nIf not involved is selected, record microscopic clearance.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-14" ], "constraint": [ { "key": "inv-14", "severity": "error", "human": "If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded.", "xpath": "not(@value = 'Not involved') or exists(f:microClearanceRectum)" } ], "binding": { "strength": "required", "description": "A code that indicates the status of the nonperitonealised circumferential margin in rectal tumours", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-involved-notinvolved" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28354.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueQuantity": { "value": 1, "comparator": "<", "unit": "mm" } } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.microClearanceRectum", "short": "Microscopic Clearance", "definition": "In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slides.", "requirements": "Is conditional.", "min": 0, "max": "1", "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28400.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.lymphNodeInvolvement", "short": "Lymph node involvement", "definition": "Results of lymph node histopathology must be recorded.", "requirements": "Single selection value list.\nConditional on nodes being received in G2.02. If G2.02 has been recorded as “not received” this standard is not required.\nIf present, record site(s) and number of lymph nodes.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-16" ], "constraint": [ { "key": "inv-16", "severity": "error", "human": "If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes.", "xpath": "not(@value = 'Present') or exists(f:lymphNodesDetails)" } ], "binding": { "strength": "required", "description": "A code that indicates lymph node involvement", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-na" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28338.1000043" }, { "identity": "loinc", "map": "?? 21892-5" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Perirectal LN basin: 2/14" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "0/8\n\n(Note for Grahame: this is classed as free text clarification as this field is normally only completed when the involvment (field above) is Present. )" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "Left, 2/21" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "Left, 2/11" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.lymphNodesDetails", "short": "Site(s) and numbers of lymph nodes", "definition": "If lymph node(s) received then the site(s) and numbers of lymph nodes must be recorded.", "comments": "Query if this field needs to be broken in to a number of fields??", "requirements": "Text: Site of lymph node\nAND\nNumeric: ____/_____\n(Number of positive nodes/ Total number of nodes from this site)\nSite is the LN drainage relevant to the site of tumour being reported.", "min": 0, "max": "*", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28403.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.extramuralTumourDeposits", "short": "Isolated extra-mural tumour deposits", "definition": "The presence or absence of isolated extra-mural tumour deposits is to be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the presence or absence of isolated extra-mural tumour deposits.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-na" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28392.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.apicalNodeInvolvement", "short": "Apical node involvement", "definition": "Involvement of the apical lymph node should be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates apical node involvement", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-na" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28407.1000043" } ] }, { "path": "Colorectal.micro.venousSmallVesselInvasion", "short": "Venous and small vessel invasion", "definition": "For all tumours, venous and small vessel invasion must be reported and its anatomic location specified as intramural or extramural.", "comments": "This is just a header and is not a data field\n?? How to be entered in the resource.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28411.1000043" }, { "identity": "sct", "map": "371512006" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Present" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.intramuralVeinInvasion", "short": "Intramural vein invasion", "definition": "Intramural invasion must be reported on.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates intramural vein invasion", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-notidentified-present" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28412.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.extramuralVeinInvasion", "short": "Extramural vein invasion", "definition": "Extramural invasion must be reported on.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates extramural vein invasion", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-notidentified-present" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28415.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.smallVesselInvasion", "short": "Small vessel invasion", "definition": "Small vessel invasion must be reported on.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates small vessel invasion", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-notidentified-present-presentextensive" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28418.1000043" }, { "identity": "sct", "map": "372264001" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Not identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Present (focal)" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.perineuralInvasion", "short": "Perineural invasion", "definition": "Perineural invasion must be reported on.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates perineural invasion", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-notidentified-present-presentextensive" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28136.1000043" }, { "identity": "loinc", "map": "33741-0" }, { "identity": "sct", "map": "371513001" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "Absent" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.histoConfDistMetastases", "short": "Histologically confirmed distant metastases", "definition": "The presence or absence of histologically confirmed distant metastases must be recorded.", "requirements": "Single selection value list.\nIf present, record sites.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "condition": [ "inv-17" ], "constraint": [ { "key": "inv-17", "severity": "error", "human": "If histologically confirmed distant metastases are present then the sites are to be recorded.", "xpath": "not(@value = 'Present') or exists(f:site)" } ], "binding": { "strength": "required", "description": "A code that indicates the presence or absence of histologically confirmed distant metastases", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-present-absent-na" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28236.1000043" }, { "identity": "sct", "map": "399608002" } ] }, { "path": "Colorectal.micro.histoConfDistMetastasesSite", "short": "Histologically confirmed distant metastases - site", "definition": "The site of histologically confirmed distant metastases must be recorded.", "requirements": "Is conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28242.1000043" }, { "identity": "loinc", "map": "21920-4" }, { "identity": "sct", "map": "385421009" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Polyps" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "None noted" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "None noted" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "None noted" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.relCoexistPathabnorm", "short": "Relevant coexistent pathological abnormalities", "definition": "The relevant coexistent pathological abnormalities must be recorded.", "requirements": "Multi select value list (select all that apply).\n?? How is this indicated??\nIf Polyps is selected provide details\nIf Ulcerative colitis or Crohn’s disease is selected record dysplasia\nIf other is selected, provide details in “other abnormality”.", "min": 1, "max": "*", "type": [ { "code": "code" } ], "condition": [ "inv-18", "inv-19", "inv-20", "inv-21" ], "constraint": [ { "key": "inv-18", "severity": "error", "human": "If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded.", "xpath": "not(@value = 'Polyps') or exists(f:polypDetails)" }, { "key": "inv-19", "severity": "error", "human": "If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.", "xpath": "not(@value = 'Ulcerative colitis') or exists(f:dysplasia)" }, { "key": "inv-20", "severity": "error", "human": "If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.", "xpath": "not(@value = 'Crohns disease') or exists(f:dysplasia)" }, { "key": "inv-21", "severity": "error", "human": "If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded.", "xpath": "not(@value = 'Other') or exists(f:otherAbnormality)" } ], "binding": { "strength": "required", "description": "A code that indicates the relevant coexistent pathological abnormalities", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-coexist-path-abnormalities" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28244.1000043" }, { "identity": "sct", "map": "371498006" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Two tubular adenomata confirmed." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.polypDetails", "short": "Polyp details (type, number, polyposis syndrome criteria met etc)", "definition": "The polyp details (type, number, polyposis syndrome criteria met etc) is to be recorded.", "requirements": "Is conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" } ] }, { "path": "Colorectal.micro.dysplasia", "short": "Dysplasia", "definition": "If Ulcerative colitis or Crohns disease is selected for relevant coexistent pathological abnormalities record dysplasia.", "comments": "Cannot have an apostrophe in a spreadsheet eg Crohn apostrophe s.", "requirements": "Single selection value list.\nIs conditional.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalities", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-dysplasia" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" } ] }, { "path": "Colorectal.micro.otherAbnormality", "short": "Other abnormality", "definition": "Record any other abnormality.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "loinc", "map": "44624-5" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Complete resection" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Complete resection" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "Complete" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "Complete" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.microResidualTumourStatus", "short": "Microscopic residual tumour status (completeness of resection)", "definition": "The microscopic residual tumour status (completeness of resection) is to be recorded.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28425.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "Grade 2 (minimal response) Residual cancer outgrown by fibrosis" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "No prior treatment" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "No prior treatment" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "No prior treatment" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.neoadjuvantTherapy", "short": "Response to neoadjuvant therapy", "definition": "The response to neoadjuvant therapy should be recorded.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates the response to neoadjuvant therapy", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-response-to-neoadjuvant-therapy" } }, "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28123.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "The submucosal nodule 20mm from the distal margin is a well differentiated carcinoid tumour, completely excised." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "The submucosal nodule 20mm from the distal margin is a well differentiated carcinoid tumour, completely excised." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "The caecal tumour is an adenocarcinoma, formed by malignant epithelial cells forming branching glands, some with cribriform pattern. These cells have pleomorphic nuclei with prominent nucleoli.\nMaximum distance of spread beyond muscularis propria: 5 mm." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.micro.microComments", "short": "Microscopic comments", "definition": "Other Microscopic comments should be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28431.1000043" }, { "identity": "sct", "map": "395527009" } ] }, { "path": "Colorectal.ancillaryTests", "short": "Ancillary test findings", "definition": "Ancillary test findings are to be recorded.", "comments": "This is just a group/section header and is not a result field, but some example reports this field was used as a comment field.", "requirements": "Immunohistochemical stains for microsatellite instability will be performed and a supplementary report issued.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "mapping": [ { "identity": "logical", "map": "ancillary := dr.result->Observation[code := %map-codes]" }, { "identity": "cap", "map": "28156.1000043" }, { "identity": "loinc", "map": "70949-3" } ] }, { "path": "Colorectal.ancillaryTests.mismatchRepairEnz", "short": "Mismatch repair enzymes", "definition": "Mismatch repair enzymes are to be recorded.", "comments": "This is just a sub-group/sub-section header and is not a result field.", "min": 1, "max": "1", "type": [ { "code": "Element" } ], "mapping": [ { "identity": "cap", "map": "28433.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Normal staining" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.ancillaryTests.mlh1", "short": "MLH-1", "definition": "MLH-1 testing.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates MLH-1 testing", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-stain-type" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28434.1000043" }, { "identity": "loinc", "map": "50322-7" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Normal staining" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.ancillaryTests.pms2", "short": "PMS-2", "definition": "PMS-2 testing.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates PMS-2 testing", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-stain-type" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28442.1000043" }, { "identity": "loinc", "map": "50328-4" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Normal staining" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.ancillaryTests.msh2", "short": "MSH-2", "definition": "MSH-2 testing.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates MSH-2 testing", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-stain-type" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28493.1000043" }, { "identity": "loinc", "map": "50323-5" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "Normal staining" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.ancillaryTests.msh6", "short": "MSH-6", "definition": "MSH-6 testing.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that indicates MSH-6 testing", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-stain-type" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28544.1000043" }, { "identity": "loinc", "map": "50324-3" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Immunohistochemistry for mismatch repair gene products: staining of carcinoma cells for MLH-1, PMS-2, MSH-2 and MSH-6 is present." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Mismatch repair gene deficiency NOT identified" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.ancillaryTests.comments", "short": "Mismatch repair enzyme comments", "definition": "Mismatch repair enzyme comments can be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28436.1000043" }, { "identity": "loinc", "map": "8262-8" } ] }, { "path": "Colorectal.ancillaryTests.msi", "short": "Microsatellite instability (MSI)", "definition": "Microsatellite instability (MSI) to be recorded.", "comments": "This is just a group/section header and is not a result field.", "requirements": "Single selection value list.\nIf unstable or stable, record laboratory performing test and report number.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "condition": [ "inv-22", "inv-23" ] }, { "path": "Colorectal.ancillaryTests.msi.code", "short": "Microsatellite instability (MSI)", "definition": "Microsatellite instability (MSI) to be recorded.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "constraint": [ { "key": "inv-22", "severity": "error", "human": "If MSI unstable, record laboratory performing test and report number", "xpath": "not(@value = 'Unstable') or exists(f:LabDetails)" }, { "key": "inv-23", "severity": "error", "human": "If MSI stable, record laboratory performing test and report number", "xpath": "not(@value = 'Stable') or exists(f:LabDetails)" } ], "binding": { "strength": "required", "description": "A code that indicates Microsatellite instability (MSI)", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-unstable-stable" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28399.1000043" }, { "identity": "loinc", "map": "email to Meagan" }, { "identity": "sct", "map": "443412009" } ] }, { "path": "Colorectal.ancillaryTests.msi.comments", "short": "Microsatellite instability (MSI) comments", "definition": "Microsatellite instability (MSI) comments can be recorded.", "requirements": "Conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28453.1000043" } ] }, { "path": "Colorectal.ancillaryTests.msi.labDetails", "short": "MSI laboratory performing test and report number", "definition": "Microsatellite instability (MSI) laboratory performing test and report number can be recorded.", "requirements": "Conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28447.1000043" } ] }, { "path": "Colorectal.ancillaryTests.braf", "short": "BRAF (V600E mutation)", "definition": "BRAF (V600E mutation) testing.", "comments": "This is just a group/section header and is not a result field.", "requirements": "Single selection value list.\nIf mutated or wild type, record laboratory performing test and report number.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "condition": [ "inv-24", "inv-25" ] }, { "path": "Colorectal.ancillaryTests.braf.code", "short": "BRAF (V600E mutation)", "definition": "BRAF (V600E mutation) testing.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "constraint": [ { "key": "inv-24", "severity": "error", "human": "If BRAF mutated, record laboratory performing test and report number", "xpath": "not(@value = 'Mutated') or exists(f:LabDetails)" }, { "key": "inv-25", "severity": "error", "human": "If BRAF wild type, record laboratory performing test and report number", "xpath": "not(@value = 'Wild type') or exists(f:LabDetails)" } ], "binding": { "strength": "required", "description": "A code that indicates the BRAF (V600E mutation)", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-mutated-wildtype" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28454.1000043" }, { "identity": "loinc", "map": "58483-9" } ] }, { "path": "Colorectal.ancillaryTests.braf.comments", "short": "BRAF (V600E mutation) comments", "definition": "BRAF (V600E mutation) comments can be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28460.1000043" }, { "identity": "loinc", "map": "8264-4" } ] }, { "path": "Colorectal.ancillaryTests.braf.labDetails", "short": "BRAF (V600E mutation) laboratory performing test and report number", "definition": "BRAF (V600E mutation) laboratory performing test and report number can be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28459.1000043" } ] }, { "path": "Colorectal.ancillaryTests.kras", "short": "KRAS gene mutation (codons 12 and 13)", "definition": "KRAS gene mutation (codons 12 and 13) testing.", "comments": "This is just a group/section header and is not a result field.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "condition": [ "inv-26", "inv-27" ] }, { "path": "Colorectal.ancillaryTests.kras.code", "short": "KRAS gene mutation (codons 12 and 13)", "definition": "KRAS gene mutation (codons 12 and 13) testing.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "constraint": [ { "key": "inv-27", "severity": "error", "human": "If KRAS wild type, record laboratory performing test and report number", "xpath": "not(@value = 'Wild type') or exists(f:LabDetails)" }, { "key": "inv-26", "severity": "error", "human": "If KRAS mutated, record laboratory performing test and report number", "xpath": "not(@value = 'Mutated') or exists(f:LabDetails)" } ], "binding": { "strength": "required", "description": "A code that indicates the KRAS gene mutation (codons 12 and 13)", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-mutated-wildtype" } }, "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28461.1000043" }, { "identity": "loinc", "map": "21703-4" } ] }, { "path": "Colorectal.ancillaryTests.kras.comments", "short": "KRAS gene mutation (codons 12 and 13) comments", "definition": "KRAS gene mutation (codons 12 and 13) comments can be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28465.1000043" }, { "identity": "loinc", "map": "8266-9" } ] }, { "path": "Colorectal.ancillaryTests.kras.labDetails", "short": "KRAS gene mutation (codons 12 and 13) laboratory performing test and report number", "definition": "KRAS gene mutation (codons 12 and 13) laboratory performing test and report number can be recorded.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28466.1000043" } ] }, { "path": "Colorectal.synthesisOverview", "short": "Synthesis and Overview", "definition": "Synthesis and Overview are to be recorded.", "comments": "This is just a group/section header and is not a result field.", "min": 0, "max": "1", "type": [ { "code": "Element" } ], "mapping": [ { "identity": "logical", "map": "synthesis := dr.result->Observation[code := %map-codes]" }, { "identity": "cap", "map": "28253.1000043" }, { "identity": "loinc", "map": "70949-3" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "ypT3, pN1b, cM0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "ypT3, pN0, cM0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "pT3, pN1, cM0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "pT3, pN1, cM0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.tumourStage", "short": "Tumour stage", "definition": "Tumour stage is to be recorded.", "comments": "This is just a sub-group/sub-section header and is not a result field.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28204.1000043" }, { "identity": "sct", "map": "371508000" } ] }, { "path": "Colorectal.synthesisOverview.tumourStageT", "short": "T", "definition": "Tumour stage T is to be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that records tumour stage T", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-tumour-stage-t" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28210.1000043" }, { "identity": "loinc", "map": "21899-0" }, { "identity": "sct", "map": "78873005" } ] }, { "path": "Colorectal.synthesisOverview.tumourStageN", "short": "N", "definition": "Tumour stage N is to be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that records tumour stage N", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-tumour-stage-n" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28220.1000043" }, { "identity": "loinc", "map": "21900-6" } ] }, { "path": "Colorectal.synthesisOverview.tumourStageM", "short": "M", "definition": "Tumour stage M is to be recorded.", "requirements": "Single selection value list.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that records tumour stage M", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-crc-tumour-stage-m" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28552.1000043" }, { "identity": "loinc", "map": "67211-3" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "IIIB" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "IIA" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "IIIB" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "IIIB" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.tumourStageGrouping", "short": "Stage grouping", "definition": "Tumour stage grouping is to be recorded.", "comments": "Check the formatting of the result group.", "requirements": "Single selection value list.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "exampleCode": "0 Tis N0 M0 |\nI T1 N0 M0 |\nT2 N0 M0 |\nIIA T3 N0 M0 |\nIIB T4a N0 M0 |\nIIC T4b N0 M0 |\nIIIA T1-T2 N1/N1c M0 |\nT1 N2a M0 |\nIIIB T3-T4a N1/N1c M0 |\nT2-T3 N2a M0 |\nT1-T2 N2b M0 |\nIIIC T4a N2a M0 |\nT3-T4a N2b M0 |\nT4b N1-N2 M0 |\nIVA Any T Any N M1a |\nIVB Any T Any N M1b", "binding": { "strength": "required", "description": "A code that records tumour stage grouping", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-tumour-stage-grouping" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28243.1000043" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "AJCC 2010, 7th edition" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "AJCC 2010, 7th edition" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.tumourStagingSystem", "short": "Year and/or edition of staging system", "definition": "Year and/or edition of staging system is to be recorded.", "requirements": "Numeric: year\nAND/OR\nText: Edition eg 1st, 2nd etc.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "loinc", "map": "? 67203-0" }, { "identity": "sct", "map": "443941007" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "R0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueString": "R0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueString": "R0" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.residualTumourStatus", "short": "Residual tumour status", "definition": "The residual tumour status must be recorded according to the AJCC Cancer Staging Manual (7th Edition).", "min": 1, "max": "1", "type": [ { "code": "string" } ], "binding": { "strength": "required", "description": "An R code that records the residual tumour status", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-residual-tumour-status" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28317.1000043" }, { "identity": "sct", "map": "17964000" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Low rectal tumour, ultralow anterior resection with proximal and distal donuts:\n- Moderately differentiated adenocarcinoma, invading into perirectal fat.\n- Less than 1mm from circumferential radial margin.\n- Proximal and distal margins free of tumour.\n- 8 lymph nodes, all benign.\n- No MSI loss detected by immunohistochemistry." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.diagnosticSummary", "short": "Diagnostic summary", "definition": "Diagnostic summary is to be recorded.", "requirements": "Include:\na. specimen type\nb. tumour site\nc. tumour type\nd. tumour stage\ne. completeness of excision.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "isSummary": true, "mapping": [ { "identity": "logical", "map": "dr[conclusion := $value]" }, { "identity": "cap", "map": "28842.1000043" }, { "identity": "loinc", "map": "34574-4" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueCode": "New primary" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueCode": "New primary" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "3" }, { "url": "exValue", "valueCode": "New primary" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "5" }, { "url": "exValue", "valueCode": "New primary" } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.newPrimaryOrRecurrence", "short": "New primary cancer or recurrence", "definition": "New primary cancer or recurrence is to be recorded.", "requirements": "Single selection value list.\nIf regional (local) recurrence or distant metastasis describe.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A code that records whether a new primary cancer or a recurrence", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/nehta-nehta-new-cancer-or-recurrence" } }, "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28472.1000043" } ] }, { "path": "Colorectal.synthesisOverview.newDescription", "short": "Describe", "definition": "Description of regional (local) recurrence or distant metastases.", "requirements": "Conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ] }, { "extension": [ { "extension": [ { "url": "index", "valueString": "1" }, { "url": "exValue", "valueString": "Mismatch repair gene deficiency is not identified." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" }, { "extension": [ { "url": "index", "valueString": "2" }, { "url": "exValue", "valueString": "Mismatch repair gene deficiency identified." } ], "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-example" } ], "path": "Colorectal.synthesisOverview.overarchingComment", "short": "Overarching comment", "definition": "Synthesis and overview overarching comment.", "requirements": "Conditional.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "logical", "map": "synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]" }, { "identity": "cap", "map": "28252.1000043" }, { "identity": "loinc", "map": "22638-1" } ] } ] } }
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.