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1) The Base64 PDF content in the example below has been truncated intentionally. Please refer to the following to link for a full example in a file. Download example here.

2) A number of test code identifiers are "LN-RCPA" codes.  These codes are LOINC codes that have been submitted to Regenstrief, but have not yet been processed. 

 

Structure Colorectal Cancer report
MSH|^~\&|MOADLEDIT^MOADLEDIT:3.1.2 (Build 6381) [win32-i386]^L|Unassigned^8D9FE669-4710-455D-8B97-811508B616E7^GUID|||20161102150514+1100||ORU^R01^ORU_R01|XX11021505120-7859|P|2.4^AUS&Australia&ISO3166_1^HL7AU-OO-201701&&L|||AL|AL|AUS
PID|1||8003608833357361^^^AUSHIC^NI~7654321^^^RMH^MR||CITIZEN^GEORGE||19640701|M|||C/o Paradise Close^^NAR NAR GOON^VIC^3812^AUS
PV1|1|O|||||||419786CW^CRUICE^ANTHONY^^^DR^^^AUSHICPR^L^^^UPIN
ORC|RE||3BE7CECB-AD59-4C46-B711-5F6E137C2890^Unassigned^8D9FE669-4710-455D-8B97-811508B616E7^GUID||CM|||||||419786CW^CRUICE^ANTHONY^^^DR^^^AUSHICPR^L^^^UPIN
OBR|1||3BE7CECB-AD59-4C46-B711-5F6E137C2890^Unassigned^8D9FE669-4710-455D-8B97-811508B616E7^GUID|84907-5^Colorectal Cancer Structured Pathology Report^LN|||20161102+1100|||||||||419786CW^CRUICE^ANTHONY^^^DR^^^AUSHICPR^L^^^UPIN||||LN=3BE7CECB-AD59-4C46-B711-5F6E137C2890||201611021450+1100||SP|F||^^^20161102+1100|419786CW^CRUICE^ANTHONY^^^DR^^^AUSHICPR^L^^^UPIN~921198YF^SMITH^MICHAEL^^^DR^^^AUSHICPR^L^^^UPIN
OBX|1|RP|60572-5^^LN^ENTRY^^EN 13606|1|CEN.RCPA-ColorectalCancer.v3^Colorectal Cancer Structured Pathology Report&99A-4DD10FEE7661CBF6&L^TEXT^Octet-stream||||||F
OBX|2|CE|70949-3^^LN^CLUSTER^^EN 13606|1.1|70949-3^Clinical details^LN||||||F
OBX|3|ST|55752-0^Clinical information^LN|1.1.1|R Colon cancer||||||F
OBX|4|ST|57723-9^Pathology Accession number^LN|1.1.2|89671-16MP||||||F
OBX|5|ST|22027-7^Operating surgeon name^LN|1.1.3|Dr Dayoub||||||F
OBX|6|CE|33725-3^Tumour location^LN|1.1.7|32713005^Caecum^SCT||||||F
OBX|7|CE|29306-8^Type of operation^LN|1.1.10|235326000^Right hemicolectomy^SCT||||||F
OBX|8|ST|81169-5^Surgeon's opinion on the existence of local residual cancer postsurgery^LN|1.1.13|Not stated||||||F
OBX|9|ST|LN-RCPA-00064^Involvement of adjacent organs^LN|1.1.14|Not stated||||||F
OBX|10|ST|LN-RCPA-00065^Regional (local) recurrence or distant metastasis^LN|1.1.16|Not stated||||||F
OBX|11|CE|70949-3^^LN^CLUSTER^^EN 13606|1.2|70949-3^Macroscopic findings^LN||||||F
OBX|12|NM|LN-RCPA-00066^Specimen length^LN|1.2.1|113|mm^^ISO+|||||F
OBX|13|CE|33725-3^Tumour site^LN|1.2.2|32713005^Caecum^SCT||||||F
OBX|14|NM|21889-1^Maximum tumour diameter^LN|1.2.3|43|mm^^ISO+|||||F
OBX|15|NM|81175-2^Distance of tumour to the nearer proximal or distal 'cut end'^LN|1.2.4|35|mm^^ISO+|||||F
OBX|16|NM|LN-RCPA-00067^Distance to nonperitonealised circumferential margin^LN|1.2.5|35|mm^^ISO+|||||F
OBX|17|CE|LN-RCPA-00068^Tumour perforation^LN|1.2.6|2667000^Absent^SCT||||||F
OBX|18|CE|LN-RCPA-00069^Relationship to anterior peritoneal reflection^LN|1.2.7|at0092^Entirely above^99A-4DD10FEE7661CBF6||||||F
OBX|19|CE|66112-4^Lymph nodes^LN|1.2.10|at0224^Received^99A-4DD10FEE7661CBF6||||||F
OBX|20|CE|70949-3^^LN^CLUSTER^^EN 13606|1.3|70949-3^Microscopic findings^LN||||||F
OBX|21|CE|LN-RCPA-00071^Tumour type^LN|1.3.1|35917007^Adenocarcinoma, NOS^SCT||||||F
OBX|22|CE|33732-9^Histological grade^LN|1.3.2|399415002^Low grade - well and moderately differentiated^SCT||||||F
OBX|23|CE|LN-RCPA-00072^Maximum degree of local invasion into or through the bowel wall^LN|1.3.3|395707006^pT3-Tumour invades through muscularis propria into pericolorectal tissues^SCT||||||F
OBX|24|CE|LN-RCPA-00073^Involvement of the proximal/distal resection ('cut end') margins^LN|1.3.4|at0143^Not involved^99A-4DD10FEE7661CBF6||||||F
OBX|25|CE|LN-RCPA-00075^Status of nonperitonealised circumferential margin (rectal tumours)^LN|1.3.8|at0241^Not involved^99A-4DD10FEE7661CBF6||||||F
OBX|26|NM|LN-RCPA-00076^Microscopic clearance^LN|1.3.9|35|mm^^ISO+|||||F
OBX|27|CE|70949-3^^LN^CLUSTER^^EN 13606|1.3.11.1|70949-3^Lymph node site/s^LN||||||F
OBX|28|ST|21893-3^Number of positive^LN|1.3.11.1.2|0||||||F
OBX|29|ST|21894-1^Total number of lymph nodes^LN|1.3.11.1.3|13||||||F
OBX|30|CE|LN-RCPA-00077^Isolated extra-mural tumour deposits^LN|1.3.12|2667000^Absent^SCT||||||F
OBX|31|CE|LN-RCPA-00078^Apical node involvement^LN|1.3.13|2667000^Absent^SCT||||||F
OBX|32|CE|70949-3^^LN^CLUSTER^^EN 13606|1.3.14|70949-3^Venous and small vessel invasion^LN||||||F
OBX|33|CE|LN-RCPA-00079^Intramural vein invasion^LN|1.3.14.2|at0146^Not identified^99A-4DD10FEE7661CBF6||||||F
OBX|34|CE|LN-RCPA-00080^Extramural vein invasion^LN|1.3.14.3|at0149^Not identified^99A-4DD10FEE7661CBF6||||||F
OBX|35|CE|33739-4^Small vessel invasion^LN|1.3.14.4|372265000^Present^SCT||||||F
OBX|36|CE|33741-0^Perineural invasion^LN|1.3.15|at0156^Not identified^99A-4DD10FEE7661CBF6||||||F
OBX|37|CE|LN-RCPA-00081^Histologically confirmed distant metastases^LN|1.3.16|2667000^Absent^SCT||||||F
OBX|38|CE|81317-0^Relevant coexistant pathological abnormalities^LN|1.3.18|260386005^None noted^SCT||||||F
OBX|39|CE|70949-3^^LN^CLUSTER^^EN 13606|1.4|70949-3^Ancillary test findings^LN||||||F
OBX|40|CE|70949-3^^LN^CLUSTER^^EN 13606|1.4.1|70949-3^Mismatch repair enzymes^LN||||||F
OBX|41|CE|50328-4^PMS-2^LN|1.4.1.2|at0195^Normal staining^99A-4DD10FEE7661CBF6||||||F
OBX|42|CE|50324-3^MSH-6^LN|1.4.1.4|at0201^Normal staining^99A-4DD10FEE7661CBF6||||||F
OBX|43|CE|43368-0^Microsatellite instablility (MSI)^LN|1.4.1.6|373121007^Not tested^SCT||||||F
OBX|44|CE|58483-9^BRAF (V600E mutation)^LN|1.4.1.9|at0208^Not tested^99A-4DD10FEE7661CBF6||||||F
OBX|45|CE|21703-4^RAS gene mutation testing^LN|1.4.1.12|373121007^Not tested^SCT||||||F
OBX|46|CE|70949-3^^LN^CLUSTER^^EN 13606|1.5|70949-3^Synthesis and overview^LN||||||F
OBX|47|CE|70949-3^^LN^CLUSTER^^EN 13606|1.5.1|21902-2^Tumour stage (AJCC 2010)^LN||||||F
OBX|48|CE|21899-0^T classification^LN|1.5.1.1|395707006^pT3^SCT||||||F
OBX|49|CE|21900-6^N classification^LN|1.5.1.2|at0292^pN0^L||||||F
OBX|50|CE|LN-RCPA-00084^Residual tumour status^LN|1.5.2|at0212^R0^99A-4DD10FEE7661CBF6||||||F
OBX|51|FT|22637-3^Diagnostic summary^LN|1.5.3|Diagnostic summary:\.br\Speciment type: Right hemicolectomy\.br\Tumour site: Caecal\.br\Tumour type: Adenocarcinoma\.br\Tumour stage: T3 N0 MX\.br\Completeness of excision: Completely excised\.br\Diagnosis:\.br\Right Colon - Moderately differentiated caecal Adenocarcinoma, T3\.br\Thirteen lymph nodes negative for metastatis (0/13)\.br\Surgical margins clear||||||F
OBX|52|ED|PDF^Display format in PDF^AUSPDI||ECLIPSE&ECLIPSE:3.1.8 [win32-i386]&L^application^pdf^Base64^JVBERi0x...||||||F

 

 

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1 Comment

  1. OBX|48|CE|21899-0^T classification^LN|1.5.1.1|395707006^pT3^SCT||||||F

    SNOMED CT concepts should not be used for structured reporting as due to licensing issue, SNOMED International only has AJCC version 6 staging concepts which are outdated. The updated information is also not available in LOINC. So, in this case, the free text AJCC staging information with version identifier needs to be available on those structured synoptic reports.