TEMPLATE British Columbia Cancer agency Breast Cancer Synoptic Report (7a30d4da-bb74-4b7f-b60d-504ce9ec989e)

TEMPLATE ID7a30d4da-bb74-4b7f-b60d-504ce9ec989e
ConceptBritish Columbia Cancer agency Breast Cancer Synoptic Report
DescriptionThis template demonstrates representation of a NEHTA Synoptic report for Melanoma histopathology
PurposeThis template demonstrates representation of a NEHTA Synoptic report for Melanoma histopathology
References
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set }
Language useden
Citeable Identifier1013.26.199
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Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Patient Identity'], code=at0000, itemType=SECTION, level=1, text=Patient Identity, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnostic Summary'], code=at0000, itemType=SECTION, level=1, text=Diagnostic Summary, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnostic Summary']/items[openEHR-EHR-EVALUATION.problem-diagnosis.v1], code=at0000.1, itemType=EVALUATION, level=2, text=Diagnosis, description=A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnostic Summary']/items[openEHR-EHR-EVALUATION.problem-diagnosis.v1]/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=3, text=Diagnosis, description=The index diagnosis, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: ac0.1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnostic Summary']/items[openEHR-EHR-EVALUATION.problem-diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, description=Description of the clinical aspects of the problem, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnostic Summary']/items[openEHR-EHR-EVALUATION.problem-diagnosis.v1]/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=3, text=Date clinically recognised, description=Date the problem was recognised by clinicians, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. 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Commonly a coded term e.g from LOINC or SNOMED-CT., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Breast Biopsy
Default value: Breast Biopsy, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0077], code=at0077, itemType=ELEMENT, level=6, text=Diagnostic service, description=The type of high-level diagnostic service e.g. biochemistry, haematology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.86], code=at0.86, itemType=CLUSTER, level=6, text=Macroscopic, description=Macroscopic findings - more than one set of findings may be recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.86]/items[at0.76], code=at0.76, itemType=CLUSTER, level=7, text=Macroscopic finding, description=A single set of macroscopic pathology findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.86]/items[at0.76]/items[at0.90], code=at0.90, itemType=ELEMENT, level=8, text=Tissue present, description=Confirmation, or otherwise, that the tissue or structure referred to by this macroscopic finding is present in the specimen for analysis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [The anatomical structure or tissue is present.]
  • Absent  [The anatomical structure or tissue is absent]
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Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0029], code=at0029, itemType=ELEMENT, level=8, text=Specimen type, description=The type of specimen to be collected e.g venous blood, prostatic biopsy., comment=null, uncommonOntologyItems={fhir_mapping=Specimen.type}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. 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Can also be used to document any known deviations from collection or handling instructions e.g patient was not fasted., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. 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Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0005], code=at0005, itemType=ELEMENT, level=8, text=Potential risk, description=Any risk or biohazard associated with collecting or handling the specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0067], code=at0067, itemType=ELEMENT, level=8, text=Collection setting, description=Identification of the setting at which the specimen was collected from a subject of care. The specimen is often collected by a healthcare provider, but may be collected directly by the patient or carer at home., comment=This specifies the specimen collection location within the healthcare environment. It enables the laboratory to ask questions about the collection of the specimen, if required. The specimen collection setting may provide additional information relevant to the analysis of the result., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0070], code=at0070, itemType=ELEMENT, level=8, text=Specimen collector identifier, description=Identifier of the person or agency responsible for collecting the specimen., comment=null, uncommonOntologyItems={fhir_mapping=Specimen.collection.collector}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0080], code=at0080, itemType=ELEMENT, level=8, text=Number of containers, description=The total number of containers holding this specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0039], code=at0039, itemType=CLUSTER, level=8, text=Specimen quality, description=Problems with the received specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0039]/items[at0042], code=at0042, itemType=ELEMENT, level=9, text=Specimen received issues, description=Specific issue with a received specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Haemolysed  [The specimen was haemolysed.]
    • Lipaemic  [The specimen was lipaemic.]
    • Incorrect transport medium  [An incorrect preservative was used when transporting the specimen.]
    • Insufficient sample  [An insufficient sample was given to undertake measurement.]
  •  Text
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  •  Coded Text
    • Handling error  [An error arose when handling the specimen.]
    • Age  [The specimen was too old to analyse accurately.]
    • Laboratory accident  [An accident occurred with the sample in the laboratory.]
    • Technical failure  [The specimen could not be analysed for technical reasons.]
  •  Text
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  •  Coded Text
    • Satisfactory  [The specimen is of sufficient quality to allow reporting.]
    • Unsatisfactory - processed  [The specimen is unsatisfactory but has been processed.]
    • Unsatisfactory - not processed  [The specimen is unsatisfactory and has not been processed.]
  •  Text
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  • 1: Score 1  [Low mitotic frequency.]
  • 2: Score 2  [Intermediate mitotic frequency.]
  • 3: Score 3  [High mitotic frequency.]
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  • 1: Score 1  [Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli.]
  • 2: Score 2  [Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses.]
  • 3: Score 3  [Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present.]
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  • 1: Tubular formation score 1  [Less than 75% of invasive carcinoma forming tubular or glandular structures.]
  • 2: Tubular formation score 2  [10-75% of invasive carcinoma forming tubular or glandular structures.]
  • 3: Tubular formation score 3  [Less than 10% of invasive carcinoma forming tubular or glandular structures.]
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  • 1: Grade 1  [Total score of 3-5.]
  • 2: Grade 2  [Total score of 6 or 7.]
  • 3: Grade 3  [Total score of 8 or 9.]
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Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.microscopy_breast_carcinoma.v1]/items[at0054]/items[at0023], code=at0023, itemType=ELEMENT, level=9, text=Non-neoplastic cellular change, description=Finding of non-neoplastic cellular change., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='2. 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Current biopsy findings']/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0.87]/items[at0.81]/items[openEHR-EHR-CLUSTER.microscopy_breast_carcinoma.v1]/items[at0060]/items[at0061], code=at0061, itemType=ELEMENT, level=9, text=Lobular neoplasia, description=Finding of lobular neoplasia., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Present - classical  [Classical lobular neoplasia is present.]
    • Present - pleomorphic  [Pleomorphic lobular neoplasia is present.]
    • Absent  [Lobular neoplasia is absent.]
    • Indeterminate  [The presence of lobular hyperplasia has not been determined.]
  •  Text
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  •  Coded Text
    • Present - classical  [Classical atypical lobular neoplasia is present.]
    • Present - pleomorphic  [Pleomorphic atypical lobular neoplasia is present.]
    • Absent  [Atypical lobular neoplasia is absent.]
    • Indeterminate  [The presence of atypical lobular neoplasia has not been determined.]
  •  Text
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  •  Coded Text
    • Present - classical  [Classical lobular carcinoma-in-situ is present.]
    • Present - pleomorphic  [Pleomorphic lobular carcinoma-in-situ is present.]
    • Absent  [Lobular carcinoma-in-situ is absent.]
    • Indeterminate  [The presence of lobular carcinoma-in-situ has not been determined.]
  •  Text
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  • Present  [Paget's disease of the nipple is present.]
  • Absent  [Paget's disease of the nipple is absent.]
  • Indeterminate  [Presence of Paget's disease of the nipple has not been determined.]
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  • Present  [Microcalcification is present.]
  • Absent  [Microcalcification is absent.]
  • Indeterminate  [Presence of microcalcification has not been determined.]
  • Present - no evidence of necrosis  [Microcalcification is present with no evidence of necrosis.]
  • Present - with evidence of necrosis  [Microcalcification is present with evidence of necrosis.]
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  • Present with necrosis  [Calcification with necrosis is present in DCIS tissue.]
  • Present without necrosis  [Calcification without necrosis is present in DCIS tissue.]
  • Absent  [Calcification is absent from DCIS tissue.]
  • Indeterminate  [Presence of calcification in DCIS tissue has not been determined.]
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  • Present (non-comedo type)  [Non-comedo type of tumour necrosis is present.]
  • Present (Comedo type)  [Comedo type of tumour necrosis is present.]
  • Absent or minimal  [Tumour necrosis is absent or minimal.]
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  • 1: Score 1  [Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli.]
  • 2: Score 2  [Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses.]
  • 3: Score 3  [Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present.]
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  • 1: Van Nuys Group 1  [Nuclear grade 1 or 2 and no necrosis.]
  • 2: Van Nuys Group 2  [Nuclear grade 1 or 2 and necrosis.]
  • 3: Van Nuys Group 3  [Nuclear grade 3 with or without necrosis.]
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  •  Coded Text
    • Solid  [Solid pattern of ductal carcinoma-in-situ.]
    • Cribriform  [Cribriform pattern of ductal carcinoma-in-situ.]
    • Micropapillary  [Micropapillary pattern of ductal carcinoma-in-situ.]
    • Apocrine  [Apocrine pattern of ductal carcinoma-in-situ.]
    • Papillary  [Papillary pattern of ductal carcinoma-in-situ.]
    • Indeterminate  [The dominant pattern of ductal carcinoma-in-situ has not been determined.]
  •  Text
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  • Positive  [Oestrogen Receptor assay result is positive.]
  • Negative  [Oestrogen Receptor assay result is negative.]
  • Equivocal  [Oestrogen Receptor assay result is equivocal.]
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  • Low  [Predominant intensity of staining is low.]
  • Intermediate  [Predominant intensity of staining is intermediate.]
  • High  [Predominant intensity of staining is high.]
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  • Positive  [Progesterone Receptor assay result is positive.]
  • Negative  [Progesterone Receptor assay result is negative.]
  • Equivocal  [Progesterone Receptor assay result is equivocal.]
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  • Low  [Predominant intensity of staining is low.]
  • Intermediate  [Predominant intensity of staining is intermediate.]
  • High  [Predominant intensity of staining is high.]
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  • Positive  [The HER2 Immunohistochemistry result is positive.]
  • Negative  [The HER2 Immunohistochemistry result is negative.]
  • Equivocal  [The HER2 Immunohistochemistry result is equivocal.]
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  • Positive  [The HER2 In situ hybridisation (ISH) result is positive.]
  • Negative  [The HER2 In situ hybridisation (ISH) result is negative.]
  • Equivocal  [The HER2 In situ hybridisation (ISH) result is equivocal.]
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  • Columnar cell changes  [Columnar cell changes are present.]
  • Intraductal papilloma  [Intraductal papilloma is present.]
  • Radial scars  [Radial scars are present.]
  • Atypical ductal hyperplasia (ADH)  [Atypical ductal hyperplasia (ADH) is present.]
  • Absent  [Non-neoplastic change is absent.]
  • Indeterminate  [Presence of non-neoplastic changes has not been determined.]
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