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Diagnosticreport-example-papsmear

Example DiagnosticReport/pap (Narrative)

Maturity Level : N/A
Responsible Owner: Orders and Observations Work Group Standards Status : Informative Compartments : Device , Encounter , Group , Patient , Practitioner

This is the narrative for the resource. See also the XML , JSON or Turtle format. This example conforms to the profile DiagnosticReport .

Acme Anatomic Pathology Services
2216 Santa Monica Blvd, Suite 114
Santa Monica, CA 90404
===============================================================
GYN CYTOLOGY (PAP SMEAR) REPORT
===============================================================

Patient: Everywoman, Eve Report Date: 2/14/2013
DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567
Patient Address: 2222 Home Street
Huntington Park
CA 90255
Order: ORD40
Physician: Careful, Adam 5742200012 (NPI)
SpecimenID: GHSID40
Collected Date: 2/11/2013
Received Date: 2/12/2013
LMP: 1/28/2013
Specimen Source: Cervical Cytology (ThinPrep)
Previously abnormal Pap? Unknown

Specimen Adequacy: Satisfactory
Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells
of undetermined significance
Hormonal Evaluations: not possible, due to presence of atypical cells
Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated
Comments: Abnormal report reviewed by pathologist for confirmation

 

 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.