Diagnose-Section (Template)
(Teildokument von Pathologiebefund)
Dieses Material ist Teil des Leitfadens Pathologiebefund.
|
Section: Diagnose
| Template ID | 1.3.6.1.4.1.19376.1.8.1.2.5 | |
| General Description | In diesem Abschnitt werden die Diagnosen übermittelt. | |
| Status | identisch zu IHE | |
| LOINC Code | Opt. | Description |
| 22637-3 | O | Pathologiebefund Diagnose |
 |
Die Diagnosen sind gemäß Diagnoseleitfaden[1] zu übermitteln! Die Darstellung wird aus den codierten Informationen (sofern z.B. aus Cancer Check List vorhanden) abgeleitet. |
Im Falle einer Tumordiagnose enthält die Diagnose die Cancer Check List, wenn vorhanden organspezifisch, als entry (s. Anlagen und IHE_PAT_Suppl._APSR_Rev.1.1)
Definition und Zweck
The Diagnosis section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
Beispiel
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.8.1.2.5'/>
<code code='22637-3' displayName='Pathology report diagnosis' 1590
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>DIAGNOSIS SECTION</title>
<text> 1.Single intact complete excision of invasive ductal carcinoma. Upper outer
quadrant, left breast. Nottingham Histologic Grade = 2 (Glandular
differenciation: Score 2, Nuclear pleomorphism: score 3, Mitotic count:
score 2). Margin uninvolvedby invasive ductal carcinoma. No DCIS.
pT2.pN1a.cM0.
2. Micrometastases, left axillary lymph node. Free of disease 17 of 18 lymph
nodes </text>
<entry> <--! Content not shown --> </entry>
</section>
</component>
