TEMPLATE Tumordiagnose Bericht (Tumordiagnose Bericht)

TEMPLATE IDTumordiagnose Bericht
ConceptTumordiagnose Bericht
DescriptionZur Repräsentation von Erkrankungsdaten einer Tumordiagnose bei Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
UseDieses Template wird verwendet, um Erkrankungsdaten zu einer Tumordiagnose bei Patienten mit einer onkologischen Diagnose aufzuzeichnen. Es sollen folgende Daten zu der Tumordiagnose wie die ICD 10 Diagnose, die ICD-O-3 Topographie, die ICD-O-3 Histologie, der klinische TNM-Status sowie der pathologische TNM-Status erfasst werden.
MisuseDieses Template soll nicht verwendet werden, um Therapien und Prozeduren, Medikationen, Laborparameter, Residualstatus, Fernmetastasen, radiologische Daten oder molekularpathologische Daten des Patienten aufzuzeichnen. Für diese Daten jeweils das eigene Template hierzu benutzen.
PurposeZur Repräsentation von Erkrankungsdaten einer Tumordiagnose bei Patienten mit einer onkologischen Diagnose im HiGHmed Projekt.
References
Authorsdate: 2020-08-13; name: Natalia Strauch; organisation: Medizinische Hochschule Hannover; email: strauch.natalia@mh-hannover.de
Other Details Languagedate: 2020-08-13; name: Natalia Strauch; organisation: Medizinische Hochschule Hannover; email: strauch.natalia@mh-hannover.de
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=HiGHmed, PARENT:MD5-CAM-1.0.1=E3BC8668BB89A4BD43BF551931977A9D, original_language=ISO_639-1::de, original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=cc5c2759d963e2c57a6a870afdbe0bbb, build_uid=b40e7def-9ba9-43b1-80ce-c0629ffebc07}
KeywordsTumordiagnose, Krebserkrankung, Onkologische Diagnose, Tumorerkrankung, Tumor, Krebsdiagnose
Language useden
Citeable Identifier1246.169.1027
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Tumordiagnose Bericht, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.problem_list.v0], code=at0000, itemType=SECTION, level=1, text=Tumordiagnose_section, description=Suggested design pattern for including a Problem List in a template., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose'], code=at0000, itemType=EVALUATION, level=2, text=Tumordiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Diagnose Name (ICD-10), description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Diagnose Beschreibung, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Seitenlokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Links (L)
  • Rechts (R)
  • Multilokuär (X)
  • Beidseitig (B)
  • Mittellinie/ Mittig (M)
  • Unbekannt (U)
  • Trifft nicht zu (T; Seitenangabe nicht sinnvoll, einschließlich Systemerkrankungen)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Erstdiagnosedatum, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_classification_icd_o.v0], code=at0000, itemType=CLUSTER, level=4, text=Tumor classification ICD-O, description=International Classification of Diseases for Oncology ICD-O-3 is a dual classification. It contains both a topographical code and a histological code for each neoplasm. The topographical describes the site of the neoplasm; in general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms. This results in a greater accuracy in the encoding of the topography of benign tumors than achieved in ICD-10. The morphological code describes the cell type of the neoplasm and its biological behaviour. It thus characterises the neoplasm itself., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_classification_icd_o.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Morphological Code ICD-O, description=To record the type of cell that has become neoplastic and its biologic activity with the morphology code according to the International classification of diseases for oncology (‎‎ICD-O)‎‎., comment=There are three parts to a complete morphology code: 4 digits – Cell type (histology) 1 digit – Behavior 1 digit – Grade, differentiation or phenotype In ICD-O morphology codes, a common root codes the cell type of a given tumor, while an additional digit codes the behavior. The grade, differentiation, or phenotype code provides supplementary information about the tumor., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_classification_icd_o.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Morphologie Beschreibung, description=To record the term (narrative description/synonyms) of the morphology code according to the International classification of diseases for oncology (‎‎ICD-O)‎‎., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_classification_icd_o.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Topography Code ICD-O, description=The topographical describes the site of the neoplasm., comment=In general, it uses the same three- or four-character codes as used in ICD-10 for malignant neoplasms., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tumor_classification_icd_o.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Topographie Beschreibung, description=To record the term (narrative description/synonyms) of the topography code according to the "International classification of diseases for oncology (ICD-O-3)"., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1], code=at0000, itemType=CLUSTER, level=4, text=TNM clinical classification, description=A framework for the clinical classification and stage grouping of malignancies using the TNM system., comment=Designated as TNM or cTNM., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Primary tumour (T), description=Assessment of the the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'T1'; or 'cT3'. Represented as 'T' or 'cT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 1
  • 1a
  • 1a1
  • 1a2
  • 1b
  • 1b1
  • 1b2
  • 1c
  • 1c1
  • 1c2
  • 1c3
  • 1d
  • 1mic
  • 2
  • 2a
  • 2a1
  • 2a2
  • 2b
  • 2c
  • 2d
  • 3
  • 3a
  • 3b
  • 3c
  • 3d
  • 3e
  • 4
  • 4a
  • 4b
  • 4c
  • 4d
  • 4e
  • a
  • is
  • is(DCIS)
  • is(LAMN)
  • is(LCIS)
  • is(Paget)
  • is(pd)
  • is(pu)
  • X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Regional lymph nodes (N), description=Assessment of the the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'NX'; or 'cN2'. Represented as 'N' or 'cN' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 0(i+)
  • 0(i-)
  • 0(i-)(sn)
  • 0(mol+)
  • 0(mol-)
  • 1
  • 1a
  • 1a(sn)
  • 1b
  • 1b a)
  • 1b b)
  • 1b c)
  • 1b d)
  • 1c
  • 1mi
  • 2
  • 2a
  • 2b
  • 2c
  • 3
  • 3a
  • 3b
  • 3c
  • 4
  • X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Distant metastasis (M), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'M1'; 'cM1a'; 'M1 PUL'; or 'cM0'. Represented as 'M' or 'cM' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • X
  • 0
  • 1
  • 1a
  • 1b
  • 1bi
  • 1bii
  • 1biii
  • 1biv
  • 1c
  • 1d
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • RX 
  • R0 
  • R1 
  • R2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • LX 
  • L0 
  • L1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • VX 
  • V0 
  • V1 
  • V2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • PnX 
  • Pn0 
  • Pn1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=5, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code in brackets . For example: 'T2(m)' or 'cT2(4)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count
  •  Boolean
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=5, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0030], code=at0030, itemType=ELEMENT, level=5, text=TNM assessment, description=Concatenation of 'T', 'N' and 'M' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0031], code=at0031, itemType=ELEMENT, level=5, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on TNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 0a
  • 0is
  • I
  • IA
  • IA1
  • IA2
  • IA3
  • IB
  • IS
  • II
  • IIA
  • IIB
  • IIC
  • III
  • IIIA
  • IIIB
  • IIIC
  • IIID
  • IV
  • IVA
  • IVB
  • IVC
  • kein Stadtium ermittelbar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=TNM Edition, description=The edition of the TNM classification system used for the assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Auflage 8
  • Auflage 7
  • Auflage 6
  • Auflage 5
  • Auflage 4
  • Auflage 3
  • Auflage 2
  • Auflage 1
Default value: Auflage 8, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1], code=at0000.1, itemType=CLUSTER, level=4, text=TNM pathological classification, description=A framework for the pathological classification and stage grouping of malignancies using the TNM system., comment=Designated as pTNM., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=5, text=Primary tumour (pT), description=Assessment of the extent of the primary tumour., comment=Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'pT1'; or 'pT3'. Represented as 'pT' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 1
  • 1a
  • 1a1
  • 1a2
  • 1b
  • 1b1
  • 1b2
  • 1c
  • 1c1
  • 1c2
  • 1c3
  • 1d
  • 1mic
  • 2
  • 2a
  • 2a1
  • 2a2
  • 2b
  • 2c
  • 2d
  • 3
  • 3a
  • 3b
  • 3c
  • 3d
  • 3e
  • 4
  • 4a
  • 4b
  • 4c
  • 4d
  • 4e
  • a
  • is
  • is(DCIS)
  • is(LAMN)
  • is(LCIS)
  • is(Paget)
  • is(pd)
  • is(pu)
  • X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0004.1], code=at0004.1, itemType=ELEMENT, level=5, text=Regional lymph nodes (pN), description=Assessment of the absence or presence and extent of regional lymph node metastasis., comment=Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'pNX'; or 'pN2'. Represented as 'pN' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 0(i+)
  • 0(i-)
  • 0(i-)(sn)
  • 0(mol+)
  • 0(mol-)
  • 1
  • 1a
  • 1a(sn)
  • 1b
  • 1b a)
  • 1b b)
  • 1b c)
  • 1b d)
  • 1c
  • 1mi
  • 2
  • 2a
  • 2b
  • 2c
  • 3
  • 3a
  • 3b
  • 3c
  • 4
  • X
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0005.1], code=at0005.1, itemType=ELEMENT, level=5, text=Distant metastasis (pM), description=Assessment of the absence or presence of distant metastasis., comment=Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'pM1'. Represented as 'pM' in the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • X
  • 0
  • 1
  • 1a
  • 1b
  • 1bi
  • 1bii
  • 1biii
  • 1biv
  • 1c
  • 1d
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Histopathological grade (G), description=Histopathological grading of the tumour., comment=Pretreatment histopathological assessment may be determined from a limited biopsy prior to formal resection. Coding with a G code appropriate for the identified tumour type and anatomical site is expected. For example: 'G2'; 'GX'; or 'low grade' for bone and soft tissue sarcoma classification. Represented as 'G' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 0
  • 1
  • 2
  • 3
  • 4
  • Differenzierungsgrad nicht bestimmbar
  • Niedriggradig maligne
  • Mittelgradig maligne
  • Hochgradig maligne
  • Trifft nicht zu
  • Borderline
  • Unbekannt
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Residual tumour (R), description=Assessment of the presence of residual tumour after treatment., comment=For example: 'R2 (Macroscopic residual tumour)'. Represented as 'R' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • RX 
  • R0 
  • R1 
  • R2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Lymphatic invasion (L), description=Assessment of invasion into the lymphatic system., comment=For example: 'L0 (No lymphatic invasion)'. Represented as 'L' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • LX 
  • L0 
  • L1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Venous invasion (V), description=Assessment of invasion into the venous system., comment=For example: 'V1 (Microscopic venous invasion)'. Represented as 'V' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • VX 
  • V0 
  • V1 
  • V2 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Perineural invasion (Pn), description=Assessment of invasion into the space surrounding nerves., comment=For example: 'Pn0 (No perineural invasion)'. Represented as 'Pn' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • PnX 
  • Pn0 
  • Pn1 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0025.1], code=at0025.1, itemType=ELEMENT, level=5, text=Multiple primary tumours (m), description=Presence of multiple simultaneous primary tumours at a single site., comment=Represented by the suffix, either as '(m)' or the number of primary tumours added to the T code. For example: 'pT2(m)' or 'pT2(4)'. Represented as 'pm' within the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count
  •  Boolean
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Multimodality therapy (y), description=Record as True if assessment is performed during or following initial multimodal therapy., comment=Represented by the prefix 'y' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Recurrent (r), description=Record as True if assessment is performed for a recurring cancer after a disease-free interval., comment=Represented by the prefix 'r' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Autopsy (a), description=Record as True if assessment is performed at postmortem examination., comment=Represented by the prefix 'a' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=5, text=Carcinoma in situ (is), description=Record as True if presence of carcinoma in situ associated with the primary tumour., comment=Represented by the prefix 'is' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0030.1], code=at0030.1, itemType=ELEMENT, level=5, text=pTNM assessment, description=Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0031.1], code=at0031.1, itemType=ELEMENT, level=5, text=Stage grouping, description=The categorisation of the anatomical stage of the tumour, usually based on pTNM assessment., comment=For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=TNM Edition, description=The edition of the TNM classification system used for the assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Auflage 8
  • Auflage 7
  • Auflage 6
  • Auflage 5
  • Auflage 4
  • Auflage 3
  • Auflage 2
  • Auflage 1
Default value: Auflage 8, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.1], code=at0.1, itemType=ELEMENT, level=5, text=Sentinel node (sn), description=Record as True if presence of metastasis within one or more sentinel node(s)., comment=Represented by the suffix 'sn' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.2], code=at0.2, itemType=ELEMENT, level=5, text=Micrometastases (mi), description=Record as True if presence of micrometastases in the regional lymph drainage area of the primary tumour., comment=Represented by the suffix 'mi' added to the 'TNM assessment'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.3], code=at0.3, itemType=ELEMENT, level=5, text=Regional lymph node ITC, description=Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry in regional lymph nodes., comment=For example 'pN0(i-) No regional lymph node metastasis histologically, negative morphological findings for ITC'; 'pN0(mol+) No regional lymph node metastasis histologically, positive non morphological findings for ITC'; or 'pN0(i+)(sn) No sentinel lymph node metastasis histologically, positive morphological findings for ITC'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • i- 
  • i+ 
  • mol- 
  • mol+ 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.tnm-pathological.v1]/items[at0.8], code=at0.8, itemType=ELEMENT, level=5, text=Distant metastasis ITC, description=Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry as distant metastases, such as bone marrow., comment=For example: 'pM0(i+)' or 'pM0(mol+)'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • i- 
  • i+ 
  • mol- 
  • mol+ 
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  • Klinisch ohne tumorspezifische Diagnostik 
  • Klinisch 
  • Spezifische Tumormarker 
  • Zytologisch 
  • Histologie einer Metastase 
  • Histologisch 
  • Unbekannt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017], code=at0017, itemType=CLUSTER, level=5, text=Diagnosesicherung, description=Zur Dokumentation der Methode, des Verfahrens oder der Information, auf welcher die Diagnosesicherheit beruht., comment=Zum Beispiel: klinisches- oder bildgebendes Verfahren, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0102], code=at0102, itemType=CLUSTER, level=6, text=Klinisch, description=Es wurde weder ein mikroskopisches, noch ein bildgebendes Verfahren für die Diagnose genutzt., comment=null, uncommonOntologyItems=null, occurencesFormal=0..3, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0102]/items[at0103], code=at0103, itemType=ELEMENT, level=7, text=Klinisches Verfahren, description=Es wurde weder ein mikroskopisches, noch ein bildgebendes Verfahren für die Diagnose genutzt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direkte Visualisierung 
  • Ausschließlich klinische Diagnose 
  • Palpation 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0102]/items[at0107], code=at0107, itemType=ELEMENT, level=7, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0108], code=at0108, itemType=CLUSTER, level=6, text=Bildgebung, description=Die Malignität wurde mit Hilfe eines bildgebenden Verfahrens durch den Kliniker berichtet., comment=null, uncommonOntologyItems=null, occurencesFormal=0..7, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0108]/items[at0109], code=at0109, itemType=ELEMENT, level=7, text=Bildgebende Verfahren, description=Die Malignität wurde mit Hilfe eines bildgebenden Verfahrens durch den Kliniker berichtet., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • MRT 
  • CT 
  • PET-CT 
  • Sonografie 
  • Nuklearmedizinische Bildgebung 
  • Röntgendiagnostik 
  • Anderes bildgebendes Verfahren 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0108]/items[at0116], code=at0116, itemType=ELEMENT, level=7, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0117], code=at0117, itemType=CLUSTER, level=6, text=Mikroskopisch, description=Die Diagnosesicherheit beruht auf einer mikroskopischen Identifikation des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=0..6, 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0117]/items[at0118], code=at0118, itemType=ELEMENT, level=7, text=Mikroskopisches Verfahren, description=Die Diagnosesicherheit beruht auf einer mikroskopischen Identifikation des Tumors., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Histologisch 
  • Zytologisch 
  • Genetischer Test 
  • Immunophänotypisierung 
  • Mikroskopische Bestätigung mit unbekannter Methode 
  • Labortest oder Labormarker 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0117]/items[at0127], code=at0127, itemType=ELEMENT, level=7, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0125], code=at0125, itemType=CLUSTER, level=6, text=Sonstige Verfahren, description=Die Diagnosesicherheit beruht auf einem alternativen Verfahren, welches in den vorherigen Elementen nicht dargestellt wurde., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0125]/items[at0126], code=at0126, itemType=ELEMENT, level=7, text=Sonstiges Verfahren, description=Die Diagnosesicherheit beruht auf einem alternativen Verfahren, welches in den vorherigen Elementen nicht dargestellt wurde., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0125]/items[at0128], code=at0128, itemType=ELEMENT, level=7, text=Zeitpunkt des Verfahrens, description=Der Zeitpunkt und das Datum, an dem das Verfahren durchgeführt wurde., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.confirmed_cancer.v1]/items[at0017]/items[at0129], code=at0129, itemType=ELEMENT, level=6, text=Kommentar, description=Weitere Informationen über die Erhebung der Diagnosesicherheit., comment=Zum Beispiel können Anmerkungen über Qualität der Diagnosesicherheit in diesem Datenelement festgehalten werden., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1], code=at0000, itemType=CLUSTER, level=4, text=Weitere Tumorklassifikation, description=Der Archetyp "Weitere Tumorklassifikation" dient zur Stadieneinteilung maligner Neoplasien nach sonstigen, weiteren Tumorklassifikationen, außer der TNM-Klassifikation., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Name der Klassifikation, description=Angabe der Bezeichnung der Klassifikation. Wenn möglich wird die Kodierung der spezifischen Klassifikation mit einer Terminologie bevorzugt., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Beschreibung des Stadium/Gruppe/Grades, description=Jede zusätzliche Beschreibung für die entsprechende Klassifikation., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Stadium/Gruppe/Grad, description=Das Stadium/die Gruppe/der Grad der Einstufung der Malignität anhand der Klassifikation., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Datum der Klassifizierungseinteilung, description=Das Datum, an dem die Klassifikation festgestellt wurde., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Auflage der Klassifikation, description=Die Auflage, auf der die Klassifikation basiert, die für die Beurteilung verwendet wurde., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.further_tumor_classification.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Kommentar, description=Ergänzende Beschreibung der weiteren Tumorklassifikation, die nicht in anderen Bereichen erfasst wurde., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=4, text=Kommentar Tumordiagnose, description=Additional narrative about the problem or diagnosis not captured in other fields., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Tumordiagnose']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=4, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase'], code=at0000, itemType=EVALUATION, level=2, text=Fernmetastase, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., 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.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Fernmetastase, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Fernmetastase(n)
  • Keine Fernmetastase
  • Unbekannt
Default value: Fernmetastase(n), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.problem_list.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Fernmetastase']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Fernmetastase Lokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Lunge (PUL)
  • Knochen (OSS)
  • Leber (HEP)
  • Hirn (BRA)
  • Lymphknoten (LYM)
  • Knochenmark (MAR)
  • Pleura (PLE)
  • Peritoneum (PER)
  • Nebenniere (ADR)
  • Nieren (KID)
  • Haut (SKI)
  • Andere Organe (OTH)
  • Generalisierte Metastasierung (GEN)
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