Case study 6 Suspected Melanoma, order for histopathology examination A 45-year-old female patient Simone Studer came for her regular skin check to the Arztpraxis of Dermatologist Armin Ahrens, and this lesion was noted: Junctions nevi consisting of seborrheic area top end and atypical network constructed of many seperate dots, structures , etc , suggesting melanocytic involvement. Excision. Attachement of dermatoscopic images Specimen: 29 x 11 x 5 mm skin ellipse Body Site: Back paralumbar left The skin sample, including the order form and the dermatoscopic image are sent to the laboratory.
Order-Referral-Form 6-histopath
id: SimoneStuder meta: identifier: 80756011110123400008 name: SimoneStuder gender: FEMALE birthDate: Jan 08, 1992 maritalStatus: verheiratet (Details : {$ech-11-maritalstatus code '2' = '2', given as 'verheiratet'}) Communications - Language Preferred * Italienisch (Schweiz) (Details : {urn:ietf:bcp:47 code 'it-CH' = 'Italian (Region=Schweiz)) true
Generated Narrative: Practitioner ArminAhrens Profile: CH Core Practitioner identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/G999999 name: Armin Ahrens (Official) telecom: ph: 033 123 22 11(Work), armin.ahrens@arztpraxis.ch Qualifications - Code * Dermatology and venereology
Generated Narrative: Organization Arztpraxis Profile: CH Core Organization identifier: GLN/7601000235503 name: Arztpraxis Messen telecom: +41555545566, info@arztpraxis.ch, http://www.arztpraxis.ch address: Doktorgasse 2 Messen 3254 CH
Generated Narrative: PractitionerRole ArminAhrensArztpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Armin Ahrens (official) organization: Organization Arztpraxis Messen
Generated Narrative: Practitioner PeterPresto Profile: CH Core Practitioner EPR identifier: GLN/7601022050702, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Peter Presto (Official) telecom: ph: 032 333 22 33(Work), peter.presto@arztpraxis.ch
Generated Narrative: Organization Gruppenpraxis Profile: CH Core Organization EPR identifier: GLN/7601000241115 name: Gruppenpraxis Olten telecom: +41555556677, info@gruppenpraxis.ch, http://www.gruppenpraxis.ch address: Gerbergasse 12 Olten 4600 CH
Generated Narrative: PractitionerRole PeterPrestoGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Peter Presto (official) organization: Organization Gruppenpraxis Olten
Generated Narrative: Practitioner EvaErlenmeyer Profile: CH Core Practitioner identifier: GLN/7601000050717, urn:oid:2.16.756.5.30.1.123.100.2.1.1/Y274589 name: Eva Erlenmeyer (Official) telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch
Generated Narrative: Organization LaborPipette Profile: CH Core Organization identifier: GLN/7601000234407 name: Labor Pipette telecom: +41223345566, info@labor-pipette.ch, http://www.labor-pipette.ch address: Laborstrasse 23 Olten 4600 CH
Generated Narrative: PractitionerRole EvaErlenmeyerLaborPipette Profile: CH Core PractitionerRole identifier: urn:oid:2.16.756.5.30.1.123.100.2.1.1/K333333 practitioner: Practitioner Eva Erlenmeyer (official) organization: Organization Labor Pipette
Generated Narrative: Specimen Skin identifier: 48736-12345-75465 accessionIdentifier: 4e99a-12345-dd333 status: Available type: 29 x 11 x 5 mm skin ellipse subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) request: ServiceRequest Pathology study Collections - Collector Collected[x] BodySite * PractitionerRole 2015-08-16 06:40:17+0000 Entire skin of lumbar region of back (body structure) Containers - Type * General specimen receptacle transport container (physical object)
Specimen from skin obtained by elliptical excision (specimen)
Entire skin of lumbar region of back (body structure)
General specimen receptacle transport container (physical object)
Generated Narrative: DiagnosticReport skin-dermatoscopy Profiles: CH LAB-Order Diagnosic Report, DiagnosticReport Dermatoscopy of skin, Diagnostic Report (Pathology) Subject Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) When For 2017-03-02 Reported 2025-05-01 10:00:00+0000 Performer Marc Mustermann, Arztpraxis Identifier http://example.org/identifiers/P44444444 Report Details
Pathology (gross & histopath, not surgical)
Optical dermatoscopy of skin (procedure)
Generated Narrative: Media skin-dermatoskopy-image status: Completed type: Image modality: Photographic image subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) created: 2023-12-17 issued: 2023-12-17 14:56:18+0000 operator: Practitioner Armin Ahrens (official) height: 661 width: 702 content id a1 contentType: image/png data: (base64 data - 433,968 base64 chars) creation: 2023-12-17
Generated Narrative: Questionnaire 6-histopath version: 1; Last updated: 2023-06-06 20:17:53+0000 Profiles: CH ORF Questionnaire, SDCBaseQuestionnaire, Extractable Questionnaire - StructureMap Structure LinkID Text Cardinality Type Flags Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> LabOrderFormExample Questionnaire http://fhir.ch/ig/ch-lab-order/Questionnaire/6-histopath#3.0.0 order Auftrag 1..1 group order.placerOrderIdentifier Auftragsnummer des Auftraggebers 0..1 string order.placerOrderIdentifierDomain Identifier Domain der Auftragsnummer des Auftraggebers 0..1 string order.fillerOrderIdentifier Auftragsnummer des Auftragsempfängers 0..1 string order.fillerOrderIdentifierDomain Identifier Domain der Auftragsnummer des Auftragsempfängers 0..1 string order.precedentDocumentIdentifier Identifier des Vorgängerdokuments 0..1 string order.notificationContactDocument Dringender Benachrichtigungskontakt für dieses Dokument 0..1 group order.notificationContactDocument.practitioner Zu benachrichtigende Person 0..1 group order.notificationContactDocument.practitioner.title Titel 0..1 string order.notificationContactDocument.practitioner.familyName Name 0..1 string order.notificationContactDocument.practitioner.givenName Vorname 0..1 string order.notificationContactDocument.practitioner.phone Telefon 0..1 string order.notificationContactDocument.practitioner.email E-Mail 0..1 string order.notificationContactDocumentResponse Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument 0..1 group order.notificationContactDocumentResponse.practitioner Zu benachrichtigende Person 0..1 group order.notificationContactDocumentResponse.practitioner.title Titel 0..1 string order.notificationContactDocumentResponse.practitioner.familyName Name 0..1 string order.notificationContactDocumentResponse.practitioner.givenName Vorname 0..1 string order.notificationContactDocumentResponse.practitioner.phone Telefon 0..1 string order.notificationContactDocumentResponse.practitioner.email E-Mail 0..1 string order.priority Auftragspriorität 0..1 choice Options: 4 options receiver Empfänger 0..1 group receiver.practitioner Empfangende Person 0..1 group receiver.practitioner.title Titel 0..1 string receiver.practitioner.familyName Name 0..1 string receiver.practitioner.givenName Vorname 0..1 string receiver.practitioner.gln GLN 0..1 string receiver.practitioner.zsr ZSR 0..1 string receiver.practitioner.phone Telefon 0..1 string receiver.practitioner.email E-Mail 0..1 string receiver.organization Empfangende Organisation 0..1 group receiver.organization.name Name der Organisation 0..1 string receiver.organization.gln GLN 0..1 string receiver.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string receiver.organization.postalCode PLZ 0..1 string receiver.organization.city Ort 0..1 string receiver.organization.country Land 0..1 string patient Patient 1..1 group patient.familyName Name 0..1 string patient.maidenName Ledigname 0..1 string patient.givenName Vorname 0..1 string patient.localPid Lokale Patienten-ID 0..1 string patient.birthDate Geburtsdatum 0..1 date patient.gender Geschlecht 0..1 choice Options: 3 options patient.maritalStatus Zivilstand 0..1 choice Definition: Patient.maritalStatus Options: 8 options patient.phone Telefon 0..1 string patient.email E-Mail 0..1 string patient.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string patient.postalCode PLZ 0..1 string patient.city Ort 0..1 string patient.country Land 0..1 string patient.languageOfCorrespondance Korrespondenssprache 0..1 choice Definition: Patient.communication:languageOfCorrespondance Value Set: DocumentEntry.languageCode patient.contactperson Kontaktperson 0..1 group Definition: Patient.contact patient.contactperson.relationship Beziehung 0..1 string Definition: Patient.contact.relationship.text patient.contactperson.familyName Name 0..1 string Definition: Patient.contact.name.family patient.contactperson.givenName Vorname 0..1 string Definition: Patient.contact.name.given patient.contactperson.phone Telefon 0..* string Definition: Patient.contact.telecom.value patient.contactperson.email E-Mail 0..1 string Definition: Patient.contact.telecom.value sender Absender 1..1 group sender.author Verantwortlicher 1..1 group sender.author.practitioner Verantwortliche Person 0..1 group sender.author.practitioner.title Titel 0..1 string sender.author.practitioner.familyName Name 0..1 string sender.author.practitioner.givenName Vorname 0..1 string sender.author.practitioner.gln GLN 0..1 string sender.author.practitioner.zsr ZSR 0..1 string sender.author.practitioner.phone Telefon 0..1 string sender.author.practitioner.email E-Mail 0..1 string sender.author.organization Verantwortliche Organisation 0..1 group sender.author.organization.name Name der Organisation 0..1 string sender.author.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string sender.author.organization.postalCode PLZ 0..1 string sender.author.organization.city Ort 0..1 string sender.author.organization.country Land 0..1 string sender.dataenterer Erfasser 0..1 group sender.dataenterer.practitioner Erfassende Person 0..1 group sender.dataenterer.practitioner.familyName Name 0..1 string sender.dataenterer.practitioner.givenName Vorname 0..1 string sender.dataenterer.practitioner.phone Telefon 0..1 string sender.dataenterer.practitioner.email E-Mail 0..1 string receiverCopies Kopieempfänger 0..1 group receiverCopy Kopieempfangende Organisation oder Person 0..* group Definition: PractitionerRole receiverCopy.organization.name Name der Organisation 0..1 string Definition: PractitionerRole.practitioner receiverCopy.practitionerRole.practitioner.title Titel 0..1 string Definition: HumanName.prefix receiverCopy.practitionerRole.practitioner.familyName Name 0..1 string Definition: HumanName.family receiverCopy.practitionerRole.practitioner.givenName Vorname 0..1 string Definition: HumanName.given receiverCopy.practitionerRole.practitioner.phone Telefon 0..1 string Definition: ContactPoint.value receiverCopy.practitionerRole.practitioner.email E-Mail 0..1 string Definition: ContactPoint.value receiverCopy.title Titel 0..1 string Definition: PractitionerRole.organization receiverCopy.practitionerRole.organization.name Name der Organisation 0..1 string Definition: Organization.name receiverCopy.practitionerRole.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string Definition: Address.line receiverCopy.practitionerRole.organization.postalCode PLZ 0..1 string Definition: Address.postalCode receiverCopy.practitionerRole.organization.city Ort 0..1 string Definition: Address.city receiverCopy.practitionerRole.organization.country Land 0..1 string Definition: Address.country receiverCopy.familyName Name 0..1 string receiverCopy.givenName Vorname 0..1 string receiverCopy.phone Telefon 0..1 string receiverCopy.email E-Mail 0..1 string receiverCopy.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string receiverCopy.postalCode PLZ 0..1 string receiverCopy.city Ort 0..1 string receiverCopy.country Land 0..1 string receiverCopy.patient Patient selbst 0..1 boolean Definition: Patient receiverCopy.relatedPerson Andere Person 0..* group Definition: RelatedPerson receiverCopy.relatedPerson.familyName Name 0..1 string Definition: RelatedPerson.name.family receiverCopy.relatedPerson.givenName Vorame 0..1 string Definition: RelatedPerson.name.given receiverCopy.relatedPerson.phone Telefon 0..* string Definition: RelatedPerson.telecom.value receiverCopy.relatedPerson.email E-Mail 0..1 string Definition: RelatedPerson.telecom.value receiverCopy.relatedPerson.streetAddressLine Strasse, Hausnummer, Postfach etc. 0..* string Definition: RelatedPerson.address.line receiverCopy.relatedPerson.postalCode PLZ 0..1 string Definition: RelatedPerson.address.postalCode receiverCopy.relatedPerson.city Ort 0..1 string Definition: RelatedPerson.address.city receiverCopy.relatedPerson.country Land 0..1 string Definition: RelatedPerson.address.country consent Einverständniserklärung 0..1 group Definition: ServiceRequest.supportingInfo consent.treatment Einverständnis des Patienten zur Behandlung 0..1 string consent.patientPrivacy Einverständnis des Patienten zum Datenschutz 0..1 string consent.research Einverständnis des Patienten zur Forschung 0..1 string consent.advancedCareDirective Patientenverfügung 0..1 string coverage Kostenträger 0..1 group Definition: insurance coverage.uvg Unfallversicherung (nach UVG) 0..1 string coverage.kvg Grundversicherung (nach KVG) 0..1 string coverage.vvg Zusatzversicherung (nach VVG) 0..1 string coverage.vvgOther Andere (nach VVG) 0..1 string previousResult Vorheriges Untersuchungsresultat 0..1 group Definition: ServiceRequest.supportingInfo previousResult.result Untersuchungsresultat 0..* string labSpecialties Labor Sparten 0..1 group labSpecialties.pathology Pathology 0..1 boolean labSpecialties.pathology.panels Pathology Panels 0..1 group Enable When: labSpecialties.pathology = labSpecialties.pathology.panels.Autopsy Autopsy report 0..1 boolean labSpecialties.pathology.panels.PathologyStudy Pathology Study 0..1 boolean labSpecialties.pathology.panels.SurgicalPathologyStudy Surgical pathology study 0..1 boolean <img src="[binary]" alt="doco" style="background-color: inherit"/> Documentation for this format Options Sets Answer options for order.priority http://hl7.org/fhir/request-priority#routine ("Routine") http://hl7.org/fhir/request-priority#urgent ("Urgent") http://hl7.org/fhir/request-priority#asap ("ASAP") http://hl7.org/fhir/request-priority#stat ("STAT") Answer options for patient.gender http://hl7.org/fhir/administrative-gender#male ("Male") http://hl7.org/fhir/administrative-gender#female ("Female") http://hl7.org/fhir/administrative-gender#other ("Other") Answer options for patient.maritalStatus http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#1 ("ledig") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#2 ("verheiratet") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#3 ("verwitwet") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#4 ("geschieden") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#5 ("unverheiratet") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#6 ("in eingetragener Partnerschaft") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#7 ("aufgelöste Partnerschaft") http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#9 ("unbekannt")
The practitioner that is to be used to pre-populate the form
Identifier Domain der Auftragsnummer des Auftraggebers
Identifier Domain der Auftragsnummer des Auftragsempfängers
Dringender Benachrichtigungskontakt für dieses Dokument
Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument
Kopieempfangende Organisation oder Person
Einverständnis des Patienten zur Behandlung
Einverständnis des Patienten zum Datenschutz
Einverständnis des Patienten zur Forschung
Generated Narrative: QuestionnaireResponse 6-histopath version: 1; Last updated: 2023-06-06 17:04:38+0000 Profile: CH ORF QuestionnaireResponse LinkID Text Definition Answer<img src="[binary]" alt="doco" style="background-color: inherit"/> 6-histopath Questionnaire:Lab Order Form Example 6-histopath order Auftrag order.placerOrderIdentifier Auftragsnummer des Auftraggebers 123 order.placerOrderIdentifierDomain Identifier Domain der Auftragsnummer des Auftraggebers urn:oid:2.16.756.5.30.1.123.100.2.1.1 order.precedentDocumentIdentifier Identifier des Vorgängerdokuments 1622f2fb-6ba3-4532-9aed-35b158def187 order.notificationContactDocument Dringender Benachrichtigungskontakt für dieses Dokument order.notificationContactDocument.practitioner Zu benachrichtigende Person order.notificationContactDocument.practitioner.title Titel Dr. med. order.notificationContactDocument.practitioner.familyName Name Erlenmeyer order.notificationContactDocument.practitioner.givenName Vorname Eva order.notificationContactDocument.practitioner.phone Telefon 033 444 55 66 order.notificationContactDocument.practitioner.email E-Mail eva.erlenmeyer@labor-pipette.ch order.notificationContactDocumentResponse Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument order.notificationContactDocumentResponse.practitioner Zu benachrichtigende Person order.notificationContactDocumentResponse.practitioner.title Titel Dr. med. order.notificationContactDocumentResponse.practitioner.familyName Name Ahrens order.notificationContactDocumentResponse.practitioner.givenName Vorname Armin order.notificationContactDocumentResponse.practitioner.phone Telefon 033 444 55 66 order.notificationContactDocumentResponse.practitioner.email E-Mail armin.ahrens@arztpraxis.ch order.priority Auftragspriorität RequestPriority routine: Routine receiver Empfänger receiver.practitioner Empfangende Person receiver.practitioner.title Titel Dr. med. receiver.practitioner.familyName Name Erlenmeyer receiver.practitioner.givenName Vorname Eva receiver.practitioner.gln GLN 7601000050703 receiver.practitioner.phone Telefon +41322552525 receiver.practitioner.email E-Mail eva.erlenmeyer@labor-pipette.ch receiver.organization Empfangende Organisation receiver.organization.name Name der Organisation Labor Pipette receiver.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. receiver.organization.postalCode PLZ 4600 receiver.organization.city Ort Olten receiver.organization.country Land Schweiz patient Patient patient.familyName Name Guggindieluft patient.maidenName Ledigname Bering patient.givenName Vorname Hans patient.localPid Lokale Patienten-ID 11.22.33.5678 patient.birthDate Geburtsdatum 1981-01-01 patient.gender Geschlecht AdministrativeGender male: Male patient.maritalStatus Zivilstand eCH-011 MaritalStatus 5: unverheiratet patient.phone Telefon 079 979 79 79 patient.email E-Mail erika@musterfrau.ch patient.streetAddressLine Strasse, Hausnummer, Postfach etc. patient.postalCode PLZ 8000 patient.city Ort Zürich patient.country Land Schweiz sender Absender sender.author Verantwortlicher sender.author.practitioner Verantwortliche Person sender.author.practitioner.title Titel Dr. med. sender.author.practitioner.familyName Name Ahrens sender.author.practitioner.givenName Vorname Armin sender.author.practitioner.gln GLN 7601000034321 sender.author.practitioner.zsr ZSR L248519 sender.author.practitioner.phone Telefon 033 123 22 11 sender.author.practitioner.email E-Mail armin.ahrens@arztpraxis.ch sender.author.organization Verantwortliche Organisation sender.author.organization.name Name der Organisation Gruppenpraxis sender.author.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. sender.author.organization.postalCode PLZ 4600 sender.author.organization.city Ort Olten sender.author.organization.country Land Schweiz sender.dataenterer Erfasser sender.dataenterer.practitioner Erfassende Person sender.dataenterer.practitioner.familyName Name Ahrens sender.dataenterer.practitioner.givenName Vorname Armin sender.dataenterer.practitioner.phone Telefon 033 123 22 11 sender.dataenterer.practitioner.email E-Mail armin.ahrens@arztpraxis.ch receiverCopies Kopieempfänger receiverCopy Kopieempfangende Organisation oder Person receiverCopy.organization.name Name der Organisation Praxis Seeblick receiverCopy.title Titel Dr. med. receiverCopy.familyName Name Meier receiverCopy.givenName Vorname Sabine receiverCopy.phone Telefon 044 333 22 11 receiverCopy.email E-Mail sabine.meier@praxisseeblick.ch receiverCopy Kopieempfangende Organisation oder Person receiverCopy.familyName Name Meier receiverCopy.givenName Vorname Sabine receiverCopy.phone Telefon 044 333 22 11 receiverCopy.email E-Mail sabine.meier@praxis.ch receiverCopy.streetAddressLine Strasse, Hausnummer, Postfach etc. receiverCopy.postalCode PLZ 6330 receiverCopy.city Ort Cham receiverCopy.country Land Schweiz labSpecialties Labor Sparten labSpecialties.pathology Pathology true labSpecialties.pathology.panels Pathology Panels labSpecialties.pathology.panels.Autopsy Autopsy report false labSpecialties.pathology.panels.PathologyStudy Pathology Study false labSpecialties.pathology.panels.SurgicalPathologyStudy Surgical pathology study true <img src="[binary]" alt="doco" style="background-color: inherit"/> Documentation for this format
Generated Narrative: ServiceRequest 6-histopath-service-request Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Urgent code: Pathology study subject: Simone Studer (official) Female, DoB: 1992-01-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400008) requester: PractitionerRole reasonCode: Suspicion Melanoma Skin reasonReference: Diagnostic Report for 'Optical dermatoscopy of skin (procedure)' for '->Simone Studer' specimen: Skin specimen
Pigmented nevus (morphologic abnormality)