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Oncology

SHR implementation of ASCO requirements.

AllredIntensityScore

Part of the Allred scoring, based on the intensity of that staining, on a scale of 0 to 3. 29749

Based On ObservationComponent

Value:  Quantity Units is 1
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 29749
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

AllredProportionScore

Part of Allred scoring, based on the percentage of cells that stain for a receptor, on a scale of 0 to 5. 31054

Based On ObservationComponent

Value:  Quantity Units is 1
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 31054
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

AllredTotalScore

The total Allred score, the total of proportion and intensity scores, from 0 to 8. 31056

Based On ObservationComponent

Value:  Quantity Units is 1
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 31056
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

Aneusomy

Aneusomy (as defined by vendor kit used) 30478

Based On ObservationComponent

Value:  CodeableConcept must be from YesNoVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 25912
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

AverageCEP17SignalsPerCell

Average number CEP17 signals per cell (dual probe only) 25911

Based On ObservationComponent

Value:  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 25911
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

AverageHER2SignalsPerCell

Average number of HER2 signals per cell 25910

Based On ObservationComponent

Value:  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 25910
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

AverageStainingIntensity

Part of the Allred scoring, based on the intensity of that staining, on a scale of 0 (Negative) to 3 (Strong). 29749

Based On ObservationComponent

Value:  CodeableConcept must be from StainingIntensityVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 29749
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

BRCA1Variant

Whether the patient has a mutation in the BRCA1 gene.

Based On GeneticVariant

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
FocalSubject is BRCA1Gene
required For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
ObservationComponent includes optional Refseq
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

BRCA2Variant

Whether the patient has a mutation in the BRCA2 gene.

Based On GeneticVariant

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
FocalSubject is BRCA2Gene
required For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
ObservationComponent includes optional Refseq
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

BreastCancer [Entry]

Finding or diagnosis of cancer originating in the tissues of the breast, and potentially spread to other organs of the body. C1446377

Based On Condition

Value:  CodeableConcept must be from BreastCancerTypeVS
A set of codes drawn from different coding systems, representing the same concept.
Category includes disease
1 or more A class or division of people or things having particular shared characteristics
Stage must be from TBD
optional The relative advancement in the course of a disease.
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical
required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity
optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality
optional The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

BreastCancerBiomarkerPanel [Entry]

Immunohistochemistry (IHC) assessment for estrogen receptor (ER) and progesterone receptor (PR) as well as IHC or in situ hybridization (ISH) determination of human epidermal growth factor receptor 2 (HER2) status 31159

Based On Observation

Value:  CodeableConcept must be from BrcaReceptorStatusVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 31159
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Members required
         where  Observation includes optional EstrogenReceptorStatus
         where  Observation includes optional ProgesteroneReceptorStatus
         where  Observation includes optional HER2ReceptorStatus
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

BreastCancerGeneticAnalysisPanel [Entry]

The status of genes known or suspected to play a role in breast cancer risk, for example, the tumor suppressor genes, BRCA1 and BRCA2.

Based On Observation

Value:  Choice optional
         |  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
         |  string
         |  boolean
         |  Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment A file that contains audio, video, image, or similar content.
         |  time
         |  dateTime
         |  TimePeriod A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity A Quantity that is an integer.
ObservationCode is TBD
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Members required
         where  Observation includes required BRCA1Variant
         where  Observation includes required BRCA2Variant
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Cellularity

Percentage of cells in a sample that are cancerous C4055283

Based On ObservationComponent

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

CertifiedBy

The agency certifying the test.

Value:  CodeableConcept must be from CertifiedByVS
A set of codes drawn from different coding systems, representing the same concept.

CompleteMembraneStainingPercent

Percentage of cells with uniform intense complete membrane staining. 25884

Based On ObservationComponent

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

DegreeOfLymphaticInvolvement

Assessment of how much cancer is in a lymph node.

Based On ObservationComponent

Value:  CodeableConcept must be from DegreeOfLymphaticInvolvementVS
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

EstrogenReceptorStatus [Entry]

Estrogen receptor alpha is the predominant estrogen receptor expressed in breast tissue and is overexpressed in around 50% of breast carcinomas. ER status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options. 31160

Based On Observation

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 16112-5
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
FindingMethod must be a SpecificLaboratoryTest
optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
ObservationComponent includes optional NuclearPositivity
includes optional AverageStainingIntensity
includes optional StainingControl
includes optional PrimaryAntibody
includes optional AllredProportionScore
includes optional AllredIntensityScore
includes optional AllredTotalScore
includes optional OtherReceptorScoringSystem
optional A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

GeneticVariant [Entry]

Whether a subject carries a mutation in a particular gene. C0678941

Based On Observation

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
FocalSubject must be from GeneIdentifierVS
required For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
ObservationComponent includes optional Refseq
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HER2byImmunohistochemistry [Entry]

HER2 status as determined by Immunohistochemistry (IHC) 31163

Based On Observation

Value:  CodeableConcept must be from HER2StatusVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is HER2 Presence in Tissue by Immunoassay (72383-3)
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ObservationComponent includes optional CompleteMembraneStainingPercent
includes optional PrimaryAntibody
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HER2byInSituHybridization [Entry]

HER2 status as determined by In Situ HybridizationISH. 31166

Based On Observation

Value:  CodeableConcept must be from HER2StatusVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is HER2 Presence in Tissue by Immunoassay (72383-3)
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ObservationComponent includes optional AverageHER2SignalsPerCell
includes optional AverageCEP17SignalsPerCell
includes optional HER2toCEP17Ratio
includes optional Aneusomy
includes optional HeterogeneousSignals
includes optional PercentageAmplified
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HER2ReceptorStatus [Entry]

HER2 receptor status. HER2 is a member of the human epidermal growth factor receptor family of proteins and is encoded by the ERBB2 oncogene. HER2 is overexpressed in 20-30% of breast tumors,10 and is associated with an aggressive clinical course and poor prognosis. HER2 status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options. 48676-1

Based On Observation

Value:  CodeableConcept must be from HER2StatusVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is HER2 Interpretation in Tissue (48676-1)
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
FindingMethod must be a SpecificLaboratoryTest
optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
SpecificLaboratoryTest must be from HER2MethodVS
The specific test code and additional details. The test name is part of the CodeableConcept.
Members required
         where  Observation includes optional HER2byImmunohistochemistry
         where  Observation includes optional HER2byInSituHybridization
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HER2toCEP17Ratio

HER2 to CEP17 Ratio (dual probe only) 49683-6

Based On ObservationComponent

Value:  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 25912
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

HeterogeneousSignals

Whether In Situ Hybridization signals were heterogeneous. 30482

Based On ObservationComponent

Value:  CodeableConcept must be from YesNoVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 30482
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

HistologicGrade [Entry]

The Elston Grade/Nottingham Score, representative of the aggressive potential of the tumor. Well differentiated (Grade 1) look similar to normal cells and are usually slow growing, while poorly differentiated cells (Grade 3) look very different than normal and are fast-growing. C1511980

Based On Observation

Value:  CodeableConcept must be from NottinghamCombinedGradeVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationComponent includes optional TubuleFormationScore
includes optional NuclearPleomorphismScore
includes optional MitoticCountScore
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Ki-67LabelingIndex

Ki-67 is a protein phosphatase whose expression is strongly associated with cell proliferation and encoded by the MKI67 gene. The Ki67 labeling index is the fraction of Ki-67-positive cells to total cells in a tumor specimen and may be useful for determining prognosis with respect to survival and disease recurrence. The more positive cells there are, the more quickly they are dividing and forming new cells. ReferenceRange: Low <10, Intermediate 10-20, >20 High C4049944

Based On Observation

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 29593-1
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ObservationComponent includes optional PrimaryAntibody
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

LargestLymphNodeSize

The largest dimension of the largest lymph node invaded by cancer cells. C1285847

Based On ObservationComponent

Value:  Quantity Units is mm
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

LymphaticInvolvement [Entry]

Description of lymph nodes contain cancer cells. C0746333

Based On Observation

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
BodySite must be from LymphSystemSubdivisionVS
required A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ObservationComponent includes optional LargestLymphNodeSize
includes optional NumberOfLymphNodesInvolved
includes optional DegreeOfLymphaticInvolvement
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

M-Stage

Part of the TNM classification system representing metastases. The system is used to describe the spread of cancer to other parts of the body. See Table 144 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm 59522-3

Based On ObservationComponent

Value:  CodeableConcept must be from TBD
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

MitoticCountScore

How fast the tumor cells are growing and dividing, determined from the number of mitotic cells present. Scored 1 to 3, with 3 being the most mitotic cells. 371472000

Based On ObservationComponent

Value:  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

N-Stage

The presence of metastases in regional lymph nodes. TNM node category for staging derived from the American Joint Committee on Cancer. See Table 147 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm 59525-6

Based On ObservationComponent

Value:  CodeableConcept must be from TBD
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

NuclearPleomorphismScore

How large and varied the nuclei of the tumor cells are. Scored 1 to 3, with 3 being the most pleomorphism.

Based On ObservationComponent

Value:  CodeableConcept must be from NuclearPleomorphismScoreVS
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

NuclearPositivity

The percentage of cells that test (stain) positive for the presence of a receptor.

Based On ObservationComponent

Value:  Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

NumberOfLymphNodesInvolved

A count of lymph nodes invaded by cancer cells of those examined.

Based On ObservationComponent

Value:  Quantity Units is 1
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

OtherReceptorScoringSystem

A scoring system other than Allred. 31062

Based On ObservationComponent

Value:  Choice optional
         |  Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
         |  string
         |  Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment A file that contains audio, video, image, or similar content.
         |  time
         |  dateTime
         |  TimePeriod A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity A Quantity that is an integer.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

PercentageAmplified

Percentage of cells with amplified HER2 signals 31073

Based On ObservationComponent

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 31073
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

PercentageInSituCarcinoma

The percentage of the cancer that is in situ, as opposed to invading other tissues.

Based On ObservationComponent

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

PrimaryAntibody

No Description 31092

Based On ObservationComponent

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 31092
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

ProgesteroneReceptorStatus [Entry]

Progesterone receptor is expressed in 65% of breast carcinomas. PR status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options. C1514471

Based On Observation

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 16113-3
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
FindingMethod must be a SpecificLaboratoryTest
optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
ObservationComponent includes optional NuclearPositivity
includes optional AverageStainingIntensity
includes optional StainingControl
includes optional PrimaryAntibody
includes optional AllredProportionScore
includes optional AllredIntensityScore
includes optional AllredTotalScore
includes optional OtherReceptorScoringSystem
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Refseq

The Reference Sequence (RefSeq) collection provides a comprehensive, integrated, non-redundant, well-annotated set of sequences, including genomic DNA, transcripts, and proteins. RefSeq sequences form a foundation for medical, functional, and diversity studies. They provide a stable reference for genome annotation, gene identification and characterization, mutation and polymorphism analysis (especially RefSeqGene records), expression studies, and comparative analyses.

Based On ObservationComponent

Value:  CodeableConcept must be from RefseqVS
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

S-PhaseFraction

An expression of the number of mitoses found in a stated number of cells. The S-phase fraction number tells you what percentage of cells in the tissue sample are in the process of copying their genetic information (DNA). This S-phase, short for synthesis phase, happens just before a cell divides into two new cells. ReferenceRange: Low <6, Intermediate 6-10, >10 High. C0812425

Based On Observation

Value:  Quantity Units is %
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ObservationCode is 29593-1
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SizeOfGrossTumorBed

The largest dimension of the gross tumor bed/fibrotic area.

Based On ObservationComponent

Value:  Quantity Units is mm
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

SpecificLaboratoryTest

The specific test code and additional details. The test name is part of the CodeableConcept. 31089

Based On FindingMethod

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
Manufacturer optional The organization producing the product or test.
ExpirationDate optional When the medication will expire.
LotNumber optional A distinctive alpha-numeric identification code assigned by the manufacturer or distributor to a specific quantity of manufactured material or product within a batch.
CertifiedBy optional The agency certifying the test.

StagingSystem

What staging system are used

Value:  string
Version optional A string identifying the particular of form of something (such as a code system or software product) that is different in some way from another form of the same thing.

StagingTiming

Indicates when the staging was done, in terms of treatment landmarks, for example, at diagnosis (clinical), at surgery(pathologic), after treatment (post-neoadjuvant), at entry to a clinical trial, or at recurrence.

Value:  CodeableConcept must be from StagingTimeVS
A set of codes drawn from different coding systems, representing the same concept.

StainingControl

Whether control cells were present. 25895

Based On ObservationComponent

Value:  CodeableConcept from StainingControlVS
(if covered)
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 25895
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

T-Stage

The size and extent of the primary tumor (greatest dimension), based on criteria from the American Joint Committee on Cancer. See Table 152 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm 59528-0

Based On ObservationComponent

Value:  CodeableConcept must be from TBD
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

TNMStage [Entry]

The stage of a cancer, assessed according to the standard established by American Joint Committee on Cancer (AJCC). TNM Stage Grouping categorizes the progression of cancer using the Roman Numeral system. See Table 140 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm 21908-9

Based On Observation

Value:  CodeableConcept must be from TBD
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 21908-9
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
FindingMethod must be from StagingMethodVS
required The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
StagingTiming optional Indicates when the staging was done, in terms of treatment landmarks, for example, at diagnosis (clinical), at surgery(pathologic), after treatment (post-neoadjuvant), at entry to a clinical trial, or at recurrence.
ObservationComponent includes optional T-Stage
includes optional N-Stage
includes optional M-Stage
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

TubuleFormationScore

A comparison between structures formed by the tumor cells as opposed to those formed by normal cells. Scored 1 to 3 with 3 being the most abnormal. 371470008

Based On ObservationComponent

Value:  CodeableConcept must be from TubuleFormationScoreVS
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

TumorDimensions [Entry]

No Description C4086369

Based On Observation

Value:  _Value
ObservationCode is TBD
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ObservationComponent includes optional TumorPrimaryDimensionSize
includes optional TumorSecondaryDimensionSize
includes optional SizeOfGrossTumorBed
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

TumorMarginDescription

Description of the edge or border of tumor in situ by radiologist or of removed tumor by pathologist.

Based On ObservationComponent

Value:  CodeableConcept must be from TumorMarginDescriptionVS
A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

TumorMargins [Entry]

The edge or border of the tissue removed in cancer surgery. The margin is described as negative or clean when the pathologist finds no cancer cells at the edge of the tissue, suggesting that all of the cancer has been removed. The margin is described as positive or involved when the pathologist finds cancer cells at the edge of the tissue, suggesting that all of the cancer has not been removed. C4086369

Based On Observation

Value:  CodeableConcept must be from PositiveNegativeIndeterminateVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is TBD
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ObservationComponent includes optional TumorMarginDescription
includes optional Cellularity
includes optional PercentageInSituCarcinoma
0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

TumorPrimaryDimensionSize

The longest diameter of the primary tumor.

Based On ObservationComponent

Value:  Quantity Units is mm
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.

TumorSecondaryDimensionSize

The longest perpendicular diameter of the primary tumor.

Based On ObservationComponent

Value:  Quantity Units is mm
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.