| TEMPLATE ID | Tumorkonferenz_Anmeldung_Section |
|---|---|
| Concept | Tumorkonferenz_Anmeldung_Section |
| Description | Zur Repräsentation von Daten einer Tumorkonferenz, die zur Anmeldung eines Patienten mit einer onkologischen Diagnose gefordert sind. |
| Use | Dieses Template wird verwendet, um Daten zu einer Tumorkonferenz von einem Patienten mit einer onkologischen Diagnose aufzuzeichnen. Es sollen Daten zu der Tumorkonferenz erfasst werden die zur Anmeldung zur Konferenz vorliegen d.h. das Datum und Typ der Tumorkonferenz, die Fragestellung, sowie die erforderlichen Ärzte und den vorstellenden Arzt. Es ist als SECTION-Template konzipiert, um dieses in Composition-Templates (z.B. Tumorboardkonferenz Bericht, MTB Vorbereitung, MTB Empfehlung o.ä.) wiederzuverwenden. Es kann eine Referenz (Verlinkung) auf eine bestimmte Tumorboardkonferenz, die primär als Composition „Tumorboardkonferenz Bericht“ dargestellt wird, darstellen. Das Aktualisieren der Section erfordert die Aktualisierung der übergeordneten Templates. Eine Composition enthält nur eine einmal verwendbare Section. Das vollständige Befüllen der Section innerhalb eines Templates ist nicht immer erforderlich, aber das Befüllen des Feldes "Name der Dienstleistung" gilt als "Mandatory". |
| Misuse | Dieses Template soll nicht verwendet werden, um das Ergebnis oder die Vorbereitungen einer Tumorkonferenz aufzuzeichnen. Für diese Daten jeweils das eigene Template benutzen. Dieses Template soll nicht verwendet werden, um andere Konferenzen außer der Tumorboardkonferenz darzustellen. Das SECTION-Template ist kein eigenständiges Template und ist nur innerhalb eines COMPOSITION-Templates zu verwenden. Das SECTION-Template ist nicht zum Aktualisieren des Konferenz-Status einer einmal angeforderten Konferenz gedacht. |
| Purpose | Zur Repräsentation von Daten einer Tumorkonferenz, die zur Anmeldung eines Patienten mit einer onkologischen Diagnose gefordert sind. |
| References | |
| Authors | date: 2021-01-12; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de |
| Other Details Language | date: 2021-01-12; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de |
| Other Details (Language Independent) |
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| Keywords | Tumorkonferenz; Tumorboard; Organtumorboard; Molekulares Tumorboard |
| Language used | en |
| Citeable Identifier | 1246.169.1430 |
| Root archetype id | openEHR-EHR-SECTION.adhoc.v1 |
| Tumorkonferenz_Anmeldung_Section | Tumorkonferenz_Anmeldung_Section: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Tumorkonferenz | Tumorkonferenz: Request for a health-related service or activity to be delivered by a clinician, organisation or agency. |
| Current Activity | Current Activity: Current Activity. |
| Description | |
| Service name | Service name: The name of the single service or activity requested. Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management.
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| Typ der Tumorkonferenz | Typ der Tumorkonferenz: Category of service requested. Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/typ-der-tumorkonferenz |
| Fragestellung | Fragestellung: A short phrase describing the reason for the request. Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'. |
| Zweitmeinung (optional) | Zweitmeinung (optional): Description of the intent for the request. For example: a referral to a specialist may have the intent of the specialist taking over responsibility for care of the patient, or it may be to provide a second opinion on treatment options. Coding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.
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| Tumorkonferenz Startdatum | Tumorkonferenz Startdatum: The date/time that marks the beginning of the valid period of time for delivery of this service. This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time. |
| Vorstellende Klinik | Vorstellende Klinik: Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed. |
| Ward | Ward: A ward is part of a medical facility that can contain rooms and other types of locations. |
| Fachabteilungsname | Fachabteilungsname: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/fachabteilungsname |
| Vorstellender Arzt | Vorstellender Arzt: An individual human being. |
| Name | Name: The unstructured name for the individual. The content of this data element may be derived from one or more components from CLUSTER.structured_name combined together as a text string. For example: 'John Markham', 'Professor Sir John Markham', 'John Markham Jnr MP'. |
| Structured name of a person | Structured name of a person: Discrete components of an individual's name. |
| Title | Title: One or more honorific form(s) of address commencing a name. Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
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| Given name | Given name: One or more unique name(s) used to identify an individual within a family group. Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case. |
| Family name | Family name: One or more name(s) that an individual has in common with a family group. Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string. |
| Liegt bereits eine Empfehlung durch ein (Organ)-Tumorboard vor? | Liegt bereits eine Empfehlung durch ein (Organ)-Tumorboard vor?: Supplementary information will be following request. Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results. |
| Primärfall (optional) | Primärfall (optional): Description of the supplementary information.
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| Anmerkungen | Anmerkungen: Additional narrative about the service request not captured in other fields. |
| Protocol | |
| Anmeldender Arzt | Anmeldender Arzt: An individual human being. |
| Name | Name: The unstructured name for the individual. The content of this data element may be derived from one or more components from CLUSTER.structured_name combined together as a text string. For example: 'John Markham', 'Professor Sir John Markham', 'John Markham Jnr MP'. |
| Structured name of a person | Structured name of a person: Discrete components of an individual's name. |
| Title | Title: One or more honorific form(s) of address commencing a name. Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
|
| Given name | Given name: One or more unique name(s) used to identify an individual within a family group. Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case. |
| Family name | Family name: One or more name(s) that an individual has in common with a family group. Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string. |
| Erforderliche Fachdisziplinen | Erforderliche Fachdisziplinen: An individual human being. |
| Fachdisziplinen | Fachdisziplinen: The relationship or role of the individual to the subject of the health record. For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
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| Case identification | Case identification: To record case identification details for public health purposes. |
| Laufende Fallnummer | Laufende Fallnummer: The identifier of this case. |