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 Example for Colorectal
<Bundle xmlns="http://hl7.org/fhir"> <id value="569e2b57-475b-4914-adb8-0148cad61683"/> <meta> <lastUpdated value="2015-11-26T14:09:48.505+11:00"/> </meta> <type value="collection"/> <entry> <resource> <DiagnosticReport> <id value="dir.1"/> <request> <reference value="DiagnosticOrder/dir.1-dio.1"/> </request> <specimen> <reference value="Specimen/dir.1-spm.1"/> </specimen> <specimen> <reference value="Specimen/dir.1-spm.2"/> </specimen> <result> <reference value="Observation/dir.1-obs.3"/> </result> <result> <reference value="Observation/dir.1-obs.14"/> </result> <result> <reference value="Observation/dir.1-obs.35"/> </result> </DiagnosticReport> </resource> </entry> <entry> <resource> <DiagnosticOrder> <id value="dir.1-dio.1"/> <reason> <text value="Pre-operative radiotherapy: Unknown Presence of any distant metastases: Unknown Other: Nil"/> </reason> <supportingInformation> <reference value="Observation/dir.1-dio.1-obs.1"/> </supportingInformation> <supportingInformation> <reference value="Observation/dir.1-dio.1-obs.2"/> </supportingInformation> </DiagnosticOrder> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-dio.1-obs.1"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27919.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="29306-8"/> </coding> <text value="*"/> </code> <valueCode value="Anterior resection"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-dio.1-obs.2"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28283.1000043"/> </coding> <text value="Pre-operative radiotherapy"/> </code> <valueCode value="Unknown"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27906.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="70949-3"/> </coding> <text value="Macroscopy"/> </code> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.4"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.5"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.6"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.7"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.8"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.9"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.10"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.11"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.12"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.3-obs.13"/> </target> </related> </Observation> </resource> </entry> <entry> <resource> <Specimen> <id value="dir.1-spm.1"/> <collection> <quantity> <value value="185"/> <unit value="mm"/> </quantity> </collection> </Specimen> </resource> </entry> <entry> <resource> <Specimen> <id value="dir.1-spm.2"/> <collection> <bodySite> <coding> <code value="Rectosigmoid junction"/> </coding> </bodySite> </collection> </Specimen> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.4"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28360.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="21889-1"/> </coding> <text value="Max. tumour diameter"/> </code> <valueQuantity> <value value="60"/> <unit value="mm"/> </valueQuantity> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.5"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28359.1000043"/> </coding> <text value="Dist. of tumour to the nearer proximal or distal "cut end""/> </code> <valueQuantity> <value value="28"/> <unit value="mm"/> </valueQuantity> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.6"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28358.1000043"/> </coding> <text value="Dist. of tumour to the nonperitonealised circumferential margin"/> </code> <valueQuantity> <value value="3"/> <unit value=".5mm (10mm above the anterior peritoneal reflection)"/> </valueQuantity> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.7"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27963.1000043"/> </coding> <text value="Tumour perforation"/> </code> <valueCode value="Absent"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.8"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28362.1000043"/> </coding> <text value="Relationship to anterior peritoneal reflection"/> </code> <valueCode value="Astride"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.9"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27967.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="33730-3"/> </coding> <text value="Intactness of mesorectum"/> </code> <valueCode value="Complete (grade 3)"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.10"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28376.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="?? 33745-1"/> </coding> <text value="Polyps"/> </code> <valueCode value="Present"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.11"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28379.1000043"/> </coding> <text value="The number, diameter and gross configuration of polyps should be summarised"/> </code> <valueString value="2 polyps"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.12"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28380.1000043"/> </coding> <text value="Other macroscopic comments"/> </code> <valueString value="Captured image of the specimen: No 1. The specimen is labelled ‘sigmoid colon and rectum’ and consists of a portion of sigmoid colon and rectum measuring 185mm in length. Sigmoid mesentery extends to a depth of 75mm. Resection margins are stapled. 28mm from the distal resection margin, there is an ulcerated lesion with raised everted edges which extends around 90% of the circumference of the bowel. The tumour measures 60mm in length and extends 15mm distal to the anterior peritoneal reflection and 45mm proximal to this reflection. Occasional sessile polyps are noted elsewhere along the mucosa. Sectioning through the tumour shows it to invade into the outer aspect of the muscularis propria to possibly just extend into adjacent pericolic fat. The tumour extends close to the serosal surface approximately 10mm above the anterior peritoneal reflection. Multiple lymph nodes are present within the pericolic fat. 2. The specimen is labelled ‘donuts’ and consists of two donuts of bowel tissue, one measuring 18mm in diameter and 6mm in length and the other 20mm in diameter and 15mm in length."/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.3-obs.13"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28381.100004299999"/> </coding> <text value="Nature and site of blocks"/> </code> <valueString value="Specimen 2: Specimen labelled: Donuts 1A proximal resection margin; 1B sessile polyps, vascular resection margin and most apical lymph node bisected; 1C distal resection margin with tumour; 1D and 1E representative sections of tumour and possible extension to anterior serosa; 1F possible invasion through muscularis propria into pericolic fat; 1G to 1K sections of all lymph nodes with multiple nodes in each block. Representative sections of each donut in 2A and 2B respectively."/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27973.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="70949-3"/> </coding> <text value="Microscopy"/> </code> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.15"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.16"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.17"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.18"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.19"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.20"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.21"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.22"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.23"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.24"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.25"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.26"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.27"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.28"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.29"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.30"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.31"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.32"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.33"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.14-obs.34"/> </target> </related> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.15"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27974.1000043"/> </coding> <text value="Tumour type"/> </code> <valueCode value="Adenocarcinoma"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.16"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="27988.1000043"/> </coding> <text value="Histological grade"/> </code> <valueCode value="Low grade – well and moderately differentiated"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.17"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28534.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="33759-2"/> </coding> <text value="Maximum degree of local invasion into or through the bowel wall"/> </code> <valueCode value="pT3 Tumour invades through muscularis propria into pericolorectal tissues"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.18"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28351.1000043"/> </coding> <text value="Involved margin(s)"/> </code> <valueCode value="Proximal Distal"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.19"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28396.1000043"/> </coding> <text value="Microscopic Clearance"/> </code> <valueQuantity> <value value="9"/> <unit value="mm (Distal)"/> </valueQuantity> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.20"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28400.1000043"/> </coding> <text value="Microscopic Clearance"/> </code> <valueQuantity> <value value="13"/> <unit value="mm"/> </valueQuantity> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.21"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28338.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="?? 21892-5"/> </coding> <text value="Lymph node involvement"/> </code> <valueCode value="Present"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.22"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28403.1000043"/> </coding> <text value="Site(s) and numbers of lymph nodes"/> </code> <valueString value="Perirectal LN basin: 2/14"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.23"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28392.1000043"/> </coding> <text value="Isolated extra-mural tumour deposits"/> </code> <valueCode value="Absent"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.24"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28407.1000043"/> </coding> <text value="Apical node involvement"/> </code> <valueCode value="Absent"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.25"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28412.1000043"/> </coding> <text value="Intramural vein invasion"/> </code> <valueCode value="Present"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.26"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28415.1000043"/> </coding> <text value="Extramural vein invasion"/> </code> <valueCode value="Not identified"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.27"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28418.1000043"/> </coding> <text value="Small vessel invasion"/> </code> <valueCode value="Not identified"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.28"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28136.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="33741-0"/> </coding> <text value="Perineural invasion"/> </code> <valueCode value="Not identified"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.29"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28236.1000043"/> </coding> <text value="Histologically confirmed distant metastases"/> </code> <valueCode value="Absent"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.30"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28244.1000043"/> </coding> <text value="Relevant coexistent pathological abnormalities"/> </code> <valueCode value="Polyps"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.31"/> <code> <text value="Polyp details (type, number, polyposis syndrome criteria met etc)"/> </code> <valueString value="Two tubular adenomata confirmed."/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.32"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28425.1000043"/> </coding> <text value="Microscopic residual tumour status (completeness of resection)"/> </code> <valueString value="Complete resection"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.33"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28123.1000043"/> </coding> <text value="Response to neoadjuvant therapy"/> </code> <valueCode value="Grade 2 (minimal response) Residual cancer outgrown by fibrosis"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.14-obs.34"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28431.1000043"/> </coding> <text value="Microscopic comments"/> </code> <valueString value="The submucosal nodule 20mm from the distal margin is a well differentiated carcinoid tumour, completely excised."/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28253.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="70949-3"/> </coding> <text value="Synthesis and Overview"/> </code> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.35-obs.36"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.35-obs.37"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.35-obs.38"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.35-obs.39"/> </target> </related> <related> <type value="has-member"/> <target> <reference value="Observation/dir.1-obs.35-obs.40"/> </target> </related> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35-obs.36"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28204.1000043"/> </coding> <text value="Tumour stage"/> </code> <valueString value="ypT3, pN1b, cM0"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35-obs.37"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28243.1000043"/> </coding> <text value="Stage grouping"/> </code> <valueCode value="IIIB"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35-obs.38"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28317.1000043"/> </coding> <text value="Residual tumour status"/> </code> <valueString value="R0"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35-obs.39"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28472.1000043"/> </coding> <text value="New primary cancer or recurrence"/> </code> <valueCode value="New primary"/> </Observation> </resource> </entry> <entry> <resource> <Observation> <id value="dir.1-obs.35-obs.40"/> <code> <coding> <system value="http://cap.org/ecc"/> <code value="28252.1000043"/> </coding> <coding> <system value="http://loinc.org"/> <code value="22638-1"/> </coding> <text value="Overarching comment"/> </code> <valueString value="Mismatch repair gene deficiency is not identified."/> </Observation> </resource> </entry> </Bundle>
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.