ARCHETYPE Tumor diagnosis confirmation (openEHR-EHR-CLUSTER.confirmed_cancer.v2)

ARCHETYPE IDopenEHR-EHR-CLUSTER.confirmed_cancer.v2
ConceptTumor diagnosis confirmation
DescriptionDescribes the highest level of diagnostic certainty recorded in the patient's medical record. Additionally, it can show which procedures were used for cancer diagnosis.
UseUse to record the highest level of diagnostic certainty reached at the time of diagnosis. Additionally, it serves to confirm the diagnosis by describing the methods and information on which the cancer diagnosis is based. This cluster archetype was specifically created for the "Specific Details" slot of the EVALUATION.problem_diagnosis archetype. The information represented by this archetype is intended to assist clinicians in better assessing a cancer diagnosis. This is particularly important when a clinician receives information about a patient's cancer diagnosis that the clinician did not make themselves. For example, when a clinician is asked to review a patient's case in a tumor board conducted by another physician.
MisuseThis archetype is exclusively designed for representing the highest level of diagnostic certainty and the confirmation of cancer diagnoses. Not to be used to record the context of other diseases.
PurposeTo record the highest level of diagnostic certainty reached at the time of diagnosis. Additionally, it serves to represent the confirmation of the diagnosis by describing the methods and information on which the cancer diagnosis is based.
References"Datenkatalog mit Merkmalsausprägungen nach ADT/GEKID Basisdatensatz 2.0.0" der Arbeitsgemeinschaft Deutscher Tumorzentren e.V. (https://www.tumorzentren.de/onkol-basisdatensatz.html)
"Diagnostic Confirmation" nach dem Standard der North American Association of Central Cancer Registries (http://ncdbpuf.facs.org/content/diagnostic-confirmation).
"International Classification of Diseases for Oncology 3rd Edition" (https://www.dimdi.de/dynamic/de/klassifikationen/icd/icd-o-3/)
AuthorsAuthor name: Simon Schumacher
Organisation: HiGHmed
Email: sschuma9@uni-koeln.de
Date originally authored: 2019-06-03
Other Details LanguageAuthor name: Simon Schumacher
Organisation: HiGHmed
Email: sschuma9@uni-koeln.de
Date originally authored: 2019-06-03
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
  • Custodian Organisation: HiGHmed
  • References: "Datenkatalog mit Merkmalsausprägungen nach ADT/GEKID Basisdatensatz 2.0.0" der Arbeitsgemeinschaft Deutscher Tumorzentren e.V. (https://www.tumorzentren.de/onkol-basisdatensatz.html) "Diagnostic Confirmation" nach dem Standard der North American Association of Central Cancer Registries (http://ncdbpuf.facs.org/content/diagnostic-confirmation). "International Classification of Diseases for Oncology 3rd Edition" (https://www.dimdi.de/dynamic/de/klassifikationen/icd/icd-o-3/)
  • Original Namespace: org.highmed
  • Original Publisher: HiGHmed
  • Custodian Namespace: org.highmed
  • MD5-CAM-1.0.1: 671FAB4BDD58EAC1638A4FF76BE5BCCE
  • Build Uid: 187d1cfa-a0d5-4d61-9868-6677faa8466a
  • Revision: 2.0.1-alpha
KeywordsTumor, Diagnosis confirmation, Diagnosis, Diagnostic certainty, Cancer, Diagnostics
Lifecyclein_development
UID232ed129-b21a-47da-bd06-111341fa857b
Language useden
Citeable Identifier1246.145.1534
Revision Number2.0.1-alpha
items
Highest diagnostic certaintyHighest diagnostic certainty: The highest level of diagnostic certainty reached at the time of diagnosis.
  • clinical diagnosis without tumor-specific diagnostics [The diagnosis was made solely through a physical examination. There is no tumor-specific diagnostic testing.]
    [LOINC::LA4383-1 | Radiography/Imaging Only]
  • clinical [The clinical diagnosis was conducted prior to the date of death. This included multiple diagnostic techniques such as X-rays, endoscopy, additional imaging modalities, ultrasound, exploratory surgery (laparotomy, etc.), and autopsy. There is no microscopic tissue diagnosis.]
    [LOINC::LA4163-7 | Clinical Dx Only]
  • specific tumor markers [There are additional biochemical and/or immunological markers that are specific to a particular tumor site.]
    [LOINC::LA4673-5 | Positive Lab/Marker Study]
  • cytological [An examination of cells from the primary site, including fluid aspirations via endoscopies or needles, has been conducted. This includes microscopic examinations of peripheral blood smears and smears from bone marrow aspirations.]
    [LOINC::LA4675-0 | Positive Cytology]
  • histology of a metastasis [A histological examination of tissue from a metastasis is available. This includes autopsy.]
  • histological [The histological examination of tissue from the primary tumor is available. This includes all cutting techniques and bone marrow biopsies. It also includes samples of the primary tumor from autopsies.]
    [LOINC::LA4674-3 | Positive Histology]
  • unknown [The diagnostic certainty is unknown.]
    [LOINC::LA4489-6 | Unknown]
Diagnostic conformationDiagnostic conformation: To document the method, procedure, or information on which the diagnostic confirmation is based.
For example: clinical or imaging procedure
ClinicalClinical: The diagnostic certainty is based on a clinical identification of the tumor.
Clinical procedureClinical procedure: No microscopic or imaging technique was used for the diagnosis.
  • direct visualization [The tumor was identified during a surgical or endoscopic procedure. There was no microscopic confirmation of the tumor.]
  • exclusively clinical diagnosis [The malignancy was reported by a physician in a medical record.]
  • palpation [The tumor was identified through palpation of the body.]
Time of the procedureTime of the procedure: The time and date when the procedure was performed.
ImagingImaging: The malignancy was reported by the clinician using an imaging technique.
Imaging proceduresImaging procedures: The malignancy was reported by the clinician using an imaging procedure.
  • MRI [Tumor diagnosis through magnetic resonance imaging.]
  • CT [Tumor diagnosis through computed tomography.]
  • PET [Tumor diagnosis through positron emission tomography.]
  • PET-CT [Tumor diagnosis through positron emission tomography combined with computed tomography.]
  • PET-MRI [Tumor diagnosis through positron emission tomography combined with magnetic resonance imaging.]
  • SPECT [Tumor diagnosis through single-photon emission computed tomography.]
  • other nuclear medcial imaging [Tumor diagnosis through another nuclear medicine imaging technique not described in the previous elements (e.g., scintigraphy, scintillation, or gamma camera).]
  • Ultrasound [Tumor diagnosis through ultrasound.]
  • X-ray diagnostics [Tumor diagnosis through X-ray.]
  • Other imaging procedures [Another imaging procedure not described in the previous elements.]
Date/time of the procedureDate/time of the procedure: The time and date when the procedure was performed
MicroscopicMicroscopic: The diagnostic certainty is based on microscopic identification of the tumor.
Microscopic procedureMicroscopic procedure: The diagnostic certainty is based on microscopic identification of the tumor.
  • histological [Histological confirmation of the tumor diagnosis. Tissue was analyzed histologically.]
  • immunophenotyping [The tumor diagnosis was confirmed through immunophenotyping.]
  • microscopic confirmation with unknown method [The tumor diagnosis was confirmed microscopically using an unknown method.]
  • laboratory test or laboratory marker [The cancer diagnosis is based on a lab test or analysis of a laboratory marker (e.g., alpha-fetoprotein for liver cancer).]
Date/Time of the procedureDate/Time of the procedure: The time and date when the procedure was performed.
Other proceduresOther procedures: The diagnostic certainty is based on an alternative method not represented in the previous elements.
Other proceduresOther procedures: The diagnostic certainty is based on an alternative method not represented in the previous elements.
Choice of:
  •  Text
  •  Coded Text
    • genetic test [The tumor diagnosis was confirmed through a genetic test.]
    • cytological [Cytological confirmation of the tumor diagnosis. Cells were analyzed in fluid. No tissue was microscopically analyzed.]
Date/time of the procedureDate/time of the procedure: The time and date when the procedure was performed.
CommentComment: Additional information about the collection of diagnostic confirmation.
For example, comments about the quality of diagnostic confirmation can be recorded in this data element.
Other contributorsNatalia Strauch (MHH, HiGHmed)
Christina Jäger-Schmidt (Universität Heidelberg, HiGHmed)
Aurelie Tomczak (Universität Heidelberg, HiGHmed)
Translators
  • English: Severin Kohler, Charite Berlin, severin.kohler@bih-charite.de