TEMPLATE Radiologische Befunde - Pankreaskarzinom (e2ef5d19-56b5-4e90-bfa2-7ddad38371d2)

TEMPLATE IDe2ef5d19-56b5-4e90-bfa2-7ddad38371d2
ConceptRadiologische Befunde - Pankreaskarzinom
DescriptionZur Dokumentation von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Pankreaskarzinom durchgeführt wurden.
PurposeZur Dokumentation von Ergebnissen und Interpretationen einer bildgebenden Untersuchung oder einer Reihe von durchgeführten bildgebenden Untersuchungen, die bei einem Patienten mit Pankreaskarzinom durchgeführt wurden.
References
Authorsdate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
Other Details Languagedate: 2019-09-10; name: Samer Abboud Alkarkoukly; organisation: Uniklinikum Köln; email: mabbouda@uni-koeln.de
OtherDetails Language Independent{licence=licence, custodian_organisation=custodian_organisation, PARENT:MD5-CAM-1.0.1=PARENT:MD5-CAM-1.0.1, original_namespace=original_namespace, original_publisher=original_publisher, custodian_namespace=custodian_namespace, MD5-CAM-1.0.1=MD5-CAM-1.0.1}
KeywordsPankreaskarzinom; Bildgebung; Diagnostik; Bildgebendes Verfahren; Bildgebende Diagnostik; bildgebend; Untersuchung; Ergebnis; Untersuchungsergebnis
Language useden
Citeable Identifier1246.169.173
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  • Initialbefund
  • nach Neoadjuvanz
  • nach lokaler Therapie
  • unter systemischer Therapie
  • Verlaufskontrolle ohne Therapie
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  • ausreichend
  • nicht diagnostisch
  • eingeschränkt
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  • ja
  • nein (Vorhandensein eines Lokalrezidivs identifizieren)
  • unklar
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For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pankreaskopf
  • Proc. uncinatus
  • Pankreaskorpus
  • Pankreasschwanz
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  • kein Kontakt
  • Kontakt ≤ 180°
  • Kontakt > 180°
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  • kein Kontakt
  • Kontakt ≤ 180°
  • Kontakt > 180°
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (3)'], code=at0000, itemType=CLUSTER, level=5, text=Gefäßkontakt (3), description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (3)']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (3)']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Gefäßkontakt AMS (Arteria mesenterica superior), description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • kein Kontakt
  • Kontakt ≤ 180°
  • Kontakt > 180°
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (4)'], code=at0000, itemType=CLUSTER, level=5, text=Gefäßkontakt (4), description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (4)']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (4)']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Gefäßkontakt VMS (Vena mesenterica superia), description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • kein Kontakt
  • Kontakt ≤ 180°
  • Kontakt > 180°
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (5)'], code=at0000, itemType=CLUSTER, level=5, text=Gefäßkontakt (5), description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (5)']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Gefäßkontakt (5)']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Gefäßkontakt PA (inkl. PA-Thrombose), description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • kein Kontakt
  • Kontakt ≤ 180°
  • Kontakt > 180°
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose'], code=at0000, itemType=CLUSTER, level=5, text=Pfortaderthrombose, description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Pfortaderthrombose']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Pfortaderthrombose, description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
  • unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Fernmetastasen'], code=at0000, itemType=CLUSTER, level=5, text=Fernmetastasen, description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Fernmetastasen']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Fernmetastasen']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Vorhandensein von Fernmetastasen, description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
  • unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Fernmetastasen']/items[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=7, text=Metastasierungsort, description=A physical site on or within the human body., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Fernmetastasen']/items[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=Metastasierungsort, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • PUL
  • OSS
  • HEP
  • BRA
  • LYM
  • MAR
  • PLE
  • PER
  • ADR
  • SKI
  • OTH
  • missing
Default value: Pankreas, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Lokalrezidiv'], code=at0000, itemType=CLUSTER, level=5, text=Lokalrezidiv, description=Imaging result as a single value or as a nested group result., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Lokalrezidiv']/items[at0001], code=at0001, itemType=CLUSTER, level=6, text=Imaging result, description=Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result.v0 and name/value='Lokalrezidiv']/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Vorhandensein eines Lokalrezidivs, description=Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
  • unklar
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Befunde']/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Examination request details, description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung'], code=at0000, itemType=OBSERVATION, level=1, text=Verlaufsbeurteilung, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1], code=at0000, itemType=CLUSTER, level=5, text=Verlaufsbeurteilung der Bildgebung, description=Beurteilung des Verlaufs des radiologischen Musters für ein bestimmtes Problem oder eine Diagnose eines Patienten zu einem bestimmten Zeitpunkt in der Relation zum einem der vorausgegangenen bildgebenden Untersuchungsergebnissen., comment=Zum Beispiel die Veränderungen der Größe eines diagnostizierten Primärtumors werden in einer Verlaufskontrolle im Vergleich zu dem Initialbefund beurteilt., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_result_progress_evaluation.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Beurteilung der Änderung, description=Die Änderung erfolgte im radiologischen Bild im Vergleich zum vorherigen Bild., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Befundkonstanz  [*]
  • Befundverbesserung  [*]
  • Befundverschlechterung  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Verlaufsbeurteilung']/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll'], code=at0000, itemType=OBSERVATION, level=1, text=Untersuchungsprotokoll, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..5, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. 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If the modality is specified by a code in the Examination result name, then this field is not required., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • CT
  • MRT
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Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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-OBSERVATION.imaging_exam_result.v0 and name/value='Untersuchungsprotokoll']/protocol[at0025]/items[at0027]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Maßnahmen-ID, description=The local identifier given to the imaging examination report., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT'], code=at0000, itemType=OBSERVATION, level=1, text=CT, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT']/data[at0001]/events[at0002]/data[at0003]/items[at0043], code=at0043, itemType=ELEMENT, level=5, text=Native Phase, description=Imaging submodality where further classification of imaging modality is required., comment=Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
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Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)'], code=at0000, itemType=OBSERVATION, level=1, text=CT (2), description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001]/events[at0002]/data[at0003]/items[at0043], code=at0043, itemType=ELEMENT, level=5, text=Spätarterielle Phase, description=Imaging submodality where further classification of imaging modality is required., comment=Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (2)']/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Examination request details, description=Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)'], code=at0000, itemType=OBSERVATION, level=1, text=CT (3), description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality)., comment=Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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-OBSERVATION.imaging_exam_result.v0 and name/value='CT (3)']/data[at0001]/events[at0002]/data[at0003]/items[at0043], code=at0043, itemType=ELEMENT, level=5, text=Venöse Phase, description=Imaging submodality where further classification of imaging modality is required., comment=Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ja
  • nein
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